CiHM 
Microfiche 


(Monographs) 


ICMH 

Collection  de 
microfiches 
(monographies) 


Canadian  Institute  for  Historical  Microreproduct'ons  /  Institut  canadien  da  mio.v^reproductions  historiques 


-10QQ 


Technical  and  Bibliographic  Notes  /  Notes  techniques  et  bibliographiques 


The  Institute  has  attempted  to  obtain  the  best  original 
copy  available  for  filming.  Features  of  this  copy  which 
may  be  bibliographically  unique,  which  may  alter  any  of 
the  images  in  the  reproduction,  or  which  may 
significantly  change  the  usual  method  of  filming  are 
checked  below. 


D 


Coloured  covers  / 
Couverture  de  couleur 


I      I    Covers  damaged  / 


Couverture  endommagde 


□    Covers  restored  and/or  laminated  / 
Couverture  restauree  et/ou  pellicul6e 

I  Cover  title  missing  /  Le  litre  de  couverture  manque 

I I    Coloured  maps  /  Cartes  geographiques  en  couleur 

□    Coloured  ink  (i.e.  other  than  blue  or  black)  / 
Encre  de  couleur  (i.e.  autre  que  bleue  ou  noire) 


Coloured  plates  and/or  illustrations  / 
Planches  et/ou  illustrations  en  couleur 

Bound  with  other  material  / 
Relie  avec  d'autres  documents 


□ 


□    Only  edition  available  / 
Seule  edition  disponible 


n 


n 


Tight  binding  may  cause  shadows  or  distortion  along 
interior  margin  /  La  reliure  serree  peut  causer  de 
I'nmbre  ou  de  la  distorsion  le  long  de  la  marge 
interieure. 

Blank  leaves  added  during  restorations  may  appear 
within  the  text.  Whenever  possible,  these  have  been 
omitted  from  filming  /  Use  peut  que  certaines  pages 
blanches  ajoutees  lors  d'une  restauration 
apparaissent  dans  le  texte,  mais,  lorsque  cela  etait 
possible,  ces  pages  n'ont  pas  ete  filmees. 


"""7   Additional  commenis  / 

—I    Commentaires  supplementaires: 


L'Institut  a  microfilme  le  meilleur  exemplaire  qu'il  lui  a 
et6  possible  de  se  procurer.  Les  details  de  cet  exem- 
plaire qui  sont  peut-etre  uniques  du  point  de  vue  bibli- 
ographique,  qui  peuvent  modifier  une  image  reproduite, 
ou  qui  peuvent  exiger  une  modification  dans  la  m6tho- 
de  normale  de  filmage  sont  indiqu6s  ci-dessous. 

Coloured  pages  /  Pages  de  couleur 

I I    Pages  damaged  /  Pages  endommagees 

□    Pages  restored  and/or  laminated  / 
Pages  restaurees  et/ou  pelliculees 

r~A   Pages  discoloured,  stained  or  foxed  / 
I — I    Pages  decolorees,  tachetees  ou  piquees 

Pages  r^°tached  /  Pages  detachees 

l\/J    Showthrough/ Transparence 


I      I    Quality  of  print  varies  / 


D 
D 


D 


Quality  inegaJR  de  I'impression 

Includes  supplementary  material  / 
Comprend  du  matenel  supplementaire 

Pages  wholly  or  partially  obscured  by  errata  slips, 
tissues,  etc.,  have  been  refilmed  to  ensure  the  best 
possible  image  /  Les  pages  totalement  ou 
partiellement  obscurcies  par  un  feuillet  d'errata,  une 
pelure,  etc.,  ont  ete  filmees  a  nouveau  de  fagon  k 
obtenir  la  meilleure  image  possible. 

Opposing  pages  with  varying  colouration  or 
discolourations  are  filmed  twice  to  ensure  the  best 
possible  image  /  Les  pages  s'opposant  ayant  des 
colorations  variables  ou  des  decolorations  sont 
filmees  deux  fois  afin  d'obtenir  la  meilleure  image 
possible. 


Pagination   is  ab   follows:      p.    [5]-64S,    [l]-[22] 


This  item  is  filmed  at  the  reduction  ratio  checked  below  / 

Ce  document  est  filme  au  taux  de  reduction  indique  ci-dessous. 


lOx 


14x 


18x 


22x 


26x 


30x 


12x 


16x 


20x 


24x 


28x 


32x 


-  TTTw;;  r-v»'^ 


*!SK 


The  copy  filmed  here  has  been  reproduced  thenks 
to  the  generosity  of: 

University  of  British  Columbia  Library 
Vancouver 


L'exemplaire  film*  fut  reproduit  gr/ce  i  la 
gAnArositA  de 

University  of  British  Columbia  Library 
Vancouver 


The  images  appearing  hare  are  the  best  quality 
possible  considering  the  condition  and  legibility 
of  the  original  copy  and  in  keeping  with  the 
filming  contract  spacificationa. 


Original  copies  in  printed  paper  cover*  are  filmed 
beginning  with  the  front  cover  and  ending  on 
the  last  page  with  a  printed  or  illustratad  impres- 
sion, or  the  back  cover  when  appropriate.  All 
other  original  copies  are  filmed  beginning  on  the 
first  page  with  a  printed  or  illustrated  impres- 
sion, and  ending  on  the  last  page  with  a  printed 
or  illustrated  impression. 


The  last  recorded  frame  on  each  microfiche 
shall  contain  the  symbol  — ^  (meaning  "CCN- 
TINUED"!,  or  the  symbol  V  (meaning  "END"), 
whichever  applies. 

Maps,  plates,  charts,  etc.,  may  be  filmed  at 
different  reduction  ratios.  Those  too  large  to  be 
entirely  included  in  one  exposure  are  filmed 
beginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diagrams  illustrate  the 
method: 


Les  images  suivantes  ont  6xi  reproduites  avec  le 
plus  grand  soin.  compte  tenu  de  la  condition  et 
de  la  nettet*  de  l'exemplaire  film*,  et  en 
conformity  avec  les  conditions  du  contrat  de 
filmage. 

Las  exemplaires  originaux  dont  la  couverture  en 
papier  est  imprimAe  sont  filmis  en  commencant 
par  le  premier  plat  et  en  terminant  soit  par  la 
derniAre  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration,  soit  par  le  second 
plat,  salon  la  cas.  Tous  les  autres  exemplaires 
originaux  sont  film*s  en  commenpant  par  la 
premi*re  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration  et  en  terminant  par 
la  derniAre  page  qui  comporte  une  telle 
empreinte 

Un  d»s  symboles  suivants  apparaitra  sur  la 
derniAre  image  de  cheque  microfiche,  selon  le 
cas:  Ifl  symbole  -^  signifie  "A  SUIVRE   .  le 
symbole  V  signifie   'FIN'. 

Les  canes,  planches,  tableaux,  etc..  peuvent  etre 
filmis  i  des  taux  de  reduction  diff^rents. 
Lorsque  le  document  est  trop  grand  pour  etre 
reproduit  en  un  naul  cliche,  il  est  film6  d  partir 
de  I'angle  supArieur  gauche,  de  gauche  i  droite. 
et  de  haut  en  bas.  en  prenant  'e  nombre 
d'images  nAcessaire.  Les  oiagrammes  suivants 
iliustrent  la  mAthode. 


1 

2 

3 

1 

2 

3 

4 

5 

6 

E^^N^^H^k 


MICROCOPY    RESOIUTION    TEST    CHART 

(ANSI  end   ISO  TEST  CHART  No     2) 


1.0 


i.l 


1.25 


;f  Ilia 


1.4 


III  2.2 
II  2.0 

I  1.8 
1.6 


^  APPLIED  IM/1GE     I 

=1  '^3    East    M<i.r     ,t.pe. 

^=  '16)   482  -  0300  -  Phone 

^=  M6)  288  -5989  -To. 


I"'-*^ 


^=m 


i#?,i 


^o//^/iagc/'s  Encyc/opcJia  of  T'laclical  ^Medicine 


Typhoid  Fever 


AND 


Typhus  Fever 

DR.  H.  CURSCHMANN 

Profi!ssorof  M^dijine,  L^iprig 

Mill  i:ii,    U  I!  II  AhDITK  iNS 


WILLIAM   OSLER,  M.D. 

Protcssor  of  th^-  PrinciFlvs  and  PtacU:^  of  McdKinc,  Jofinii  Hopkii 
University,  B.ilt(mor»; ,   Md, 


Al   rilnKI/KlJ    iKA.V^I  AlliiN    IKiiM   Tin.  (iKKMAX,   LNDKR  TlIK 
i;iil  li  iklAi,  '-IT'KKVISIOX  I  il- 

ALFRED  STENGEL,  M.D. 

Prof -ssor  of  Cliiiic.il  Medicine  in  the  University  of  Pcniisylviiiia 


PHILADELPHIA  AND  LONDON 

W.    B.    SAUNDERS    &    COMPANY 
1901 


(■■•v\  iii'.M  I.  I'tnl. 
Kc''i.>lurvii  at  Statiunui-'  liitll,  l.i.minii.  I.tiu'lan-I. 


ELECTBOTYHtD  QV 
WE8TC0TT  A  THOMSON     PhilADA. 


PRESS  or 

W   B    SAUNOENS  fc  c.:;mp 


PREFACE. 


I  in:  iNcillciiic  nf  ilic  -iric,  ,,('  iin»ii<(^rni|)lis  i-iu'd  imil(>r  tlio  iMlitor- 
-ln|ii.t'  l'r.,i;-~o|-  .N.p||iii;ijj;rl  li;i>  l)c.ii  i( cii.iii/cl  l,v  all  wli.i  arc  Mitli- 
■  iciitlv  liiMiiliar  uitli  (uiimmii  {>,  read  ilii-c  unrk-,  ami  the  >cric:  has 
li'iinil   a    not    iiicmi-iilciaiiir  |ii(p|H)rtic.ii   it['  it.,   ili-tiiiiiitiou    in    ijij,  and 

iillici  Kii-li-li— iicakinu- iirics.     I  have -o  ottcii  lu>ar<i  rcLn-it  cxiip-mkI 

by  ihii-c  ulio-c  lark  of  tiiinilia'ity  witli  (  nTnian  kept  tlic-c  work-  liwuntl 
tli(  ir  ivacli,  iliat  1  was  ula.l  ol'  il„.  o|,|.o;iniiiiv  to  a"i>t  in  the  lirin^rin>r 
out  of  an  ilM-li-li  cilition.  it  wa^  .-j..rially  ^Tatityiiii.r  to  tin. I  that  tin- 
pi-oiniiK'iit  ^|M'iiali-l-  who  wciv  invitcl  to  ro-o|..ratr  \<\  iditinj.-  M|iai-;itc 
voinnic-  uciv  a-  int.'iv-lr.l  a-  my-rit'  in  the  matter  of  |.ulilifatioii  (,|-aii 
[■jiMJi-h  clition.  Th.  -(■  chtois  have  Imimi  n(|nc-tc<i  to  make  >nch  addi- 
tion-^ to  tlu;  ori-iNal  ai'li.-lr^  as  -crni  iirc-sify  to  thoni  to  hrinu.  the 
arll.lc-  fully  u\<  to  date  and  at  llir  ~:m\v  time  to  adapt  them  thonni<rldy 
to  thr  Aniciican  oi-  j-aiuli-h  ivad.r.  Th,.  naiuo  of  th.' cditofs  alone 
sum.'.,  t..  a-niv  th.'  pnpf.-sir.n  that  in  the  ad.liti.nis  thciv  will  he  |„v- 
S.IV..I  th,.  >ain.'  hioj,  Mandar.1  ..f  ..x....i|(.ii.r  that  has  hccn  s..  (■..ii>piciio!i.s 
;i  (.•alMiv  in  the  (ifiuinal  (icrniaii  arli.'lc-. 

In  all  ca-.'s  f  he  ( Jcnnaii  anth.ir  has  I.|.(mi  consiiltod  with  rrirard  '.>  tiio 
|)Ml)licati.)n  of  thi-  ...iiti.in  .,f  liis  w.irk,  and  has  ^dvcn  sptrific  (•..nscnt. 
In  one  case  ..iily  it  was  niifbrtnnatcly  iit>ccssaiy  to  siil.-titiite  (Wr  the 
tiaiislati.)!!  .,f  ih.>  (Jci-nian  aiti.'lc  an  cntiivly  new  ..nc  hv  an  American 
anth.ir,  ..n  a.<'..iMit  ..f  a  previous  arranirenicnt  of  the  ( Jernian  a.ithor  to 
i"N.'  a  tr:in-lati..n  of  iiis  arti.l.'  M'parat.'ly  from  this  series.  With  this 
e.\.i'|)ti.Hi  the  .\.ithiiat;cl  series  will  he  i)resentcd  inta.n. 

ALFRED  STENCiEI^ 

7 


u»^ 


^ 


.  J^^^ 


I3j£lt4; 


EDITOR'S   PREFACE. 


Ir\vM~«itli  ilic  i:iv;it<~i  |il(:i-mv  iIimI  I  iiiidcrtook,  wiili  tin'  In'lp 
<il'  Dr.  <  I'lc ,  .1  iiiciiilii'i'  i<\'  my  -t:itV,  ilic  oliiiiij;  of  a  tniii^hiiicni  .if  I'y,,- 
t(-«ur  Ciii-iliniMMir--  iMi|M(rtaiil  \v  irlv  on  Typliii-  and  'I'vplinid  Kcvcis. 

Tlio  (>ri;;in:il  idition  is  niuMni/cd  l,\  all  -|>c(ial  -tiidcnt^  of  ty|(li<iid 
fiver  a-  tlic  standard  antli(iiil\  i.n  tlic  Milijirt.  I'litfosor  <  iii'scliinanii 
lia-  liad  ;\iv|itiMn:il  ii|i|Kirtnniti(-  l<>  stndy  the  di-ra~(s  ron^idci-ol  in 
'lii-  II ^'i:i|ili.  "Iiirh  di-|(lays  I'vcfywlicic  the  tli<if(inir|niiss  and  lid- 
in—  uliiili  wr  all  iV(MMrii/c  a-  i'liai-aftiTi-ti<-  of  tlic  littrai'v  work  of  tlit- 
diriciiiiv  III'  till'  ni'cal    Miiilical  I'linirs  in  (Jcrinanv. 

\\  illi  till'  niiiscnt  III'  I'rutl'^'.or  <  nr-i'lnnami,  the  ad<litioti-  liavc  Imvii 

iiiadi'  -.1  as  to  run  -inoiiihly  with    tl rijriiiaj  text.      Tlic  liillowiiij,'  arc 

^"iiii'   "I    till'    nmri'    iin|iorlant    iliaiiv'-,  iircc-sitati'il    rhicllv  liv  the   new 
Work  done  sinii'  tlir  i->ni'  of  the  ( icrinan  nlilioii  ; 

Till' rha|)t<'r  on  the  Il'iiiirinluLry  of  'lyphoid  Vivrr  has  l)c<'n  tiior- 
oiiirhly  revii'Wid  and  inw  niatirial  added,  partirniarlv  on  the  distrihn- 
lioii  of  the  typhoid  l.acilli,  rspccially  in  tlic  uriiic,  in  the  rose-spot«,  and 
ill  the  lilooij, 

III  the  chaptir  on  patholoi_ry  niaiiy  iniimr  additions  have  Im'.mi  made, 
and  the  i.iipi.rtaiit  work  of  .Mallory  has  lieen  iiieor|Minited.  The  litera- 
Iiir,'  on  the  loeaiized  lesion-  <lue  to  the  l)aeillii-,  partieniarjv  of  the 
hoiii'-,  ineiiiiiir.'s,  heart,  pleiii-a.  Madder,  etc.,  has  Keen  earefnlly  revised 
.ind  iiroiiirht  np  to  date.      ThayerV  exhaustive  study  of  the  state  of  tlie 

''' '  ''•''  '"'III  utilized.      The  -npirieal  eomplieation- of  the  di-ease  have 

I'eiii  very  lidly  revi-ed  with  the  aid  ot'  Keen'-  inonoirraph. 

""■    ''li'ipiii'  on    I'erfoi-ation    and    I'eritonitjs    ha-    I n    practieallv 

rewi-ittin,    as    ha-    aUo    the    -eetimi    on    the    ITipatie    Coniplieatiuiis    of 
lyphoid    |'\'V('r. 

Many  important  a<ldition-  have  Keen  m.ide  to  the  seetimi  on  Diaj;- 
iio-i-  \>y  liaeterioliiMi,.  MrthiHl-,  |.artieiilarly  with  refeiviiee  to  the  recent 
Work  on  lilood-eiiltiires  ami  on  the  detection  ,,f  th,.  haeilli    in  the  urine. 

Ill  the  chapter  .m  Treatment  I  lininil  little  to  chaiiL'c.      The  author's 

i) 


10 


i:i>ii'ii:s  mil  \i  i:. 


iiiitliiid-  ill  till  ;i|i|>lic'aliMii  ..I  Inilri.tln  ia|i\  ilitllr  -■iriiiwIiMl  trnin  lli^.-r 
III  11-1  in  tlii-  I  Miiiiirv  ,  .iml  tlh  ;niti|i\  iitii'  ilriii,'--  mii-  nut  imirli  m  ii-c 
III  iv,      \\  rii^li!  -  iiii'tli'i<l  "I   .iiiiiiv  [iliiiiii  VMi'i'inuliiiii  lias  ln'iii  aijiliil. 

I     wi-ll     111    r\]lli   --     acaill     ai'.     llliji  lltrllm-.^   In    !'r.   <'ii|r,    V.hn-r     \\i.r'< 

li:i-  iiiaili'  liiiii  |iritlill\  t'aiiiiliai'  uilji  all  tln'  n n  lit  -liiilii-  mi  llir  -iili- 
jiii.  ami  wliii  lia-.  iiiui-niN  ii .  iilili/nl  in  tlir  rivi-imi  llir  ailirlfs  in 
tin  "Stiiijii-  in  |\|iliiiiil  I'l  \  I  !• '  iVmn  lln'  .Inlin-  Hii|ikin-  lluspilal, 
|iartiinlarl\  iImi-i'..I'  I 'r-.  I'li  \ni  r,  r'ininy,  Tl  m_\  it,  lilunirr,  I'aiMiii-, 
( 'n-liinp,  (  aiiiar,    I  laniliuri;ii',  ami  (iu_\ii. 

WII.I.IAM  usI.KK. 


•:/^U: 


~^7^JI^-  *:'^^^^'i'Hf^^  ■"  r^^  y^^i^-j 


CONTENTS. 


TYPHOID  FEVER. 


Etiology 

IliMMl-ii'lll 

.Mlpr|lll'p|lli.'y   IIM.I    Hioldi'V  iif   till      r\|illoii|.I!;iril|||., 
liy    wli:it     Itmilr    .|o    the    'I'volKii,!.  |{Mci||i     l.rav.'    tlic    l5o.lv  of  |li,. 
i':iliilil  ■' 

'I'llc    VilMlil\     uf    lllc    'rvililui.l-liMcllli 

Ilnu    ilo   111,.  Ty|ilii)iii-I!:icilli   (lain    Aov-    i,,   die    ISihIv   ,,i'  ilic 

lii.liviiliial    liil'ccli'.l  '.' 
The  M..M   Iin|.niiaiil  Cani,  r-   an, I  .M,iJ.>  ,,t'   I  )ivsfiiiiiialiiiii  nf  llic 

\  irii>  

'rraii,-irii»i,iii  I Iiivinl'Ii  til,'  Air 

SLiiilii'ari,','  .,f  lOarlii  in  llic  MlinlnirN  , 

InfiTlion  an. I   I  )i>^,aninali,pn  tlinaii'li  II,,iis.-li.,|(|  Artirlc-  ... 

Factors  I liat   Favnr  Int'c-linn  an, I   1  )i.-,-.aninali,,n  ,it'  the  Disca.sf 

Faii,,rs  IJclaliMLr  to  tlic  Imliv  iilual 

Kxtirnal.  not  Iinlividiial,  Intlni'ncis 

('onclii?.ions 


17 
17 
■M 

:;2 
.•i4 


.■:x 


40 
4» 
51 
r,4 

55 
56 
70 
77 


Pathology 

ricncral  Svni|it<iinato|oi.'v  

SimiMiary  ,if  the  r,,st-iMort(Mn  Coinlilion- 

External   Aii|)carMiiccs 

^[llscles.   IJoiics,  ami  .loints 

Diiri'stivc  OrL'ans 

Ilt-art  anil  \'as,-ular  System 

The  S|,l,.en 

Tile  Frinarv  ()rLrans 

Tile  Itesjiiratory  ( )rL''ans 

Tliu  Nervous  System 
Analysis  of  the  Iniliviihial  Syniptonis.     ( 'oinplications 

Alterati,ins  in  tlii'  Kxternal  Iiueiruinent 


79 
7!> 

«« 

Mfi 
X7 

yo 

104 
107 
110 
113 
118 
122 
124 


■^r^^^^^*'  **- ■ 


12  <'isri:.\rs. 

Cniirx'  nf  the    I-"rvcr  :    lv]>(ii:il   ( 'omlilion  of  the  liijiiv-'rciii- 

|itralurr  1:>:! 

Cliaiii;!-  ill  tin-  (iri-ulalory  (  )|-L:Mn.- l"i'_' 

S|ilrrii  :ui(l  Tliyrniil  (ihiml ITi; 

t  imiiii-lrinMrv  i  )|-L'aii.- l-^l 

(ii-ncralivf  Oriraiis l!»t 

Diiri^iivf  Oriruiis IDII 

Ivopiratiiry  t  >ri;aii> 2:'.S 

Nervous  Syslfin  ami  <  )riraiis  of  Special  Sen>e l!."i'.( 

Variations  in  Sviiiploinaloloirv  and  ('oiir>e 2«7 

'i'iie  l.aleiil  \'ariei'  's .';(l."> 

Seven'  aiiil  Mijilerale  ( 'a<es  o|'  Atypical  ( 'oiirse  and  Svniptoin- 

aioloiry .-Ill 

Typhoid     Fever    in   whicli    Synipioni.-    ret'eraMe    to    ('eria''i 

<  •riraiis  or  Systems   I'redoiiiinale ;!lt) 

Association  of  'ryplioid  Fever  uitli  Other  Diseases  ....  '.'rjl 
\ 'ariation>  in  ('oiirse  DepenilinL'  upon  Constitution.  Se.\,  aial 

A-e :;2i» 

Kernidex'eliees  and    ijtdapses :!4  . 

( 'oI'ValeM'elKM :;titi 

<ieneral  ('onrse olid 

(haiiires  in  Individual  ( )rLran> .'IT-'l 

■file  I)uration  of  ( 'onvaloceiire ;'„S(| 

The  d'ofd   Duration  of  thi'  Disease :\si) 

Fatal  Terndiiation.      l'ro;.'-nosis :\s2 

Time  ol'   Death        .'!?«7 

<'au.se  ot'  Di-a'h       .'is.s 

Sudden  Death .'ilKI 

Diagnosis 41  m 

<'linical  Invostiu'ation 4(11 

Special   DitPprential  DiaL'iiosis 410 

BacterioloL'ic  DiaLTiiopia 41!' 

Methods  of  Serum-DinL'uosis 42:'> 

Prophylaxis  of  the  Disease 4.S1 

(ieiieral  Measures       4.'!1 

Ite^'ulations  of  the  Sewaire-* 'ouilitions 4-11 

Water-Suppiv \:',-2 

Food  a~  a  Source  of  ii.fection 4-'U 

Prophylaxis  w  iih  Helation  to  the  Individual 4'14 

Treatment 44ii 

OiiMTvaiioiis  on  Spc'i'ific  Treatment 44:i 

N'lrsini:  and  Diet 44-! 


<(i.\TJ-:.\r<s.  i;} 

Dill  iluiiii;;   the   I'eriiiil   uf  Ui'f'eivesi'fnci;   ;uiil  the  Shige  of  Ciin- 

valf.icciici' 4.")1 

Tlie  So-Calltil  Aiiti|iyrt'tic  .Mctlinclw  uf  Tri'iitineiit       4.");5 

Hy(lniiliora]iy 454 

Aiitipyrt'tic  .Miilicaini'iils  4(!() 

Treiitiuuiil  iif  llif  DisiinlcTs  (if  Jiidiviiiual  Organs  and  Svstpiiis  4()."{ 

Treatiui'iit  nl'  (  (iiivali'sccMcc 471 

TYPHUS   FEVER. 

Historical 475 

Etiology 4X0 

Origin  and  Mddo  of  'ri-aiisinis.-ii(Mi  of  tlie  Ciiiitafriuni 4H0 

Geograpliic 4H1 

Tlu'    Nature    and    Mode    of   Action   of   the    Tv]iiuis    Fever 

Contagiinii      4h2 

Predis|«)sing  Conditioi;!* 48S) 

Personal  Conditions 4Mi) 

Season  and  Meteorologic  ( 'omiitioiis 497 

Cienei-al  Manifestations  of  tlie  Disease 497 

Pathologfy 500 

(ieneral  PVatures 600 

The  Stage  of  Iiu'ul)ation ."^OO 

The  Siihsecjuont  Course  of  the  Disease 500 

Morliid  Anatomy ,')07 

The  External  Findings r)07 

The  Clianges  in  the  Respiratory  Organs      50H 

The  Circulatory  Organs r)10 

The  Digestive  Organs 5]0 

The  Spleen -,]  [ 

The  Oenito-Frinary  Organs 512 

The  Nervous  Sy^teIn 512 

Symptomatology 513 

The  TemiH'rature 513 

Alterations  in  the  Circulatory  Organs 523 

The  Spleen  and  Lymph-Clauds 526 

Changes  in  the  Skin 527 

The  Nervous  System  and  Organs  of  Special  Sense     ....  5:54 

Disturbances  of  the  Special  Senses 540 


14  (oMi:.\Ts. 

PAGE 

(■liaiii:cs  ill  liir  Iifs|iir:ii(iry  Otlmiis 542 

Allfniliiiiis  ill  the  1  )i;.'f>tivc 'rracl 547 

('li;iii;:i>  ill  ilic  ( Iciiilii-lriiiiirv  (  )rLr.'iii.-* 54H 

Varialiipiir.  ill  the  ( 'niiivf  ami  Maiiilotalinn,.*  ot'  iIh'  I  )i>ca?e   .     .  "(."il 

Iirlapsis  ami  Iicoiincmcs 551 

X'ariatiniis  in  the  CdurM' 554 

lirlaiiniiv  111,  ami  ( 'nl•\i^lt■m■l■  witii.  (Illicr  |)iM'ascs     ....  562 

The  KlI'iMi  cit'  ( 'iiii>litiiliiiii,  .\t:c,  ami  Sex 5((5 

DiiraliiHi  lit'  tlic  I)i>*t'a>c  ami  I'itIihI  nf  ('iiiivali';^rrn''e    .     .     .  5()9 

ViTv  Si'Vrn- anil  l-'alal  ('a.-r>.      I'riiL'misis  ami  Murlaiitv   .     .  575 

I'l-i.-iii'-ir-.      Moilalily 5x.'} 

Diagnosis 594 

(iiiin-al  ( 'Mii>iilcraliinis      594 

nili'iTriiiial  IiiaLTiioi-  i'.i  Iiiiiial  .^laLTi' 595 

l)iai:mi.--i>  ill  Stairt'  nt'  Krii|iiioii 598 

Ty|iliiis  ami  'l'\  phiiiil   Iliwnhr 5!I9 

(MluT  I)iirrri  niial  SiLTii-  licturcii  'ry|iliu>  ami  'r\|ilmiil       ....  tiOO 

Prophylaxis      ()04 

licuulatiiiii  nf  (  uiu  ral  am'  Lnral  1  ly^'ii'iiii' ♦'mililiiins      ....  (504 

Isiilatimi tiOH 

'rraii-liiirlalinii  nt'  l'aliMit> (>06 

Wa.-iiiiii:  nf  IIn>|,iial  Clotliiiii: ti07 

Dij^iiit'criiiiL'- (  liitliiiiir.  etc HOH 

I)i>iiiicriiiiii  lit'  Siik-Kiiiiiiis 609 

Disinl'criiiiii  III'  FiiriiisliiiiLrs ti(l9 

ItfL:ulatii)ii>  lu\!.'anliii,i.'  DiM-liarire  of  ( 'inivalrM'i'iit.-s 610 

Treatment <>12 

S|nritlc  '{"rcaliiuMit 612 

(ii'iicral   Prcatiiiciii.  Nursiiiir.  ami  Diet 613 

Hyili-otlii'ra)iy 619 

Trcaliufiit  of  S|it'('ial  ( 'iimlitioiis  ami  ( •rLraiiif  Ciiaii^re?      ....  622 

Literature      «29 

Index ^i'^rt 


^i^l^^^^^SifM 


TYPHOID  FEVER. 


i 


V^i^sik 


TYPHOID   FEVER. 


1.  ETIOLOGY. 

HISTORICAL. 

Tin:  r,  coin  I  it  ion  ofthf  (aiisiiiv,-  lii.tor,  arid  of  tlic  iiatiiiv  uf  tvplioid 
t;v(T  \va>  ion-  iHvvciitcd  l,_v  the  iiialiility  cicarlv  to  M'pai-at,-  it  iiiialoini- 
.■allv  and  .lliiically  fVoni  otlicr  di-ca--..-  licarin-c  a  Mipcrticial  ivsctnl.lancf 
to  it.  Altlioiii,r|i  til,,  nam..  t.v|iliiis  dates  hatk  to  anti<niity,  it  was  not 
iiiilil  williin  ivccnt  times  apj.lied  to  a  elearly  detine.l  .lisea.sf,  hut  to  a 
,-roii|,,,|-  acute  iM.ii'e  conditions  attended  witli  >tn|.or  and  olwni-ation 
of  e..nseionsiiess  (rO^'.iC,  Ineatli,  va|H.r).  Tvpiiuid  (ever  i>,  without 
donht,  not  a  di-ease  tliat  lias  develo|M(l  or  appeared  f,r  the  Hrst  time 
within  th<  la-t  fvw  .vntiiries.  fei-taiii  statements  and  d.-eriptions  made 
even  l)y  early  wiitei-s_Ms,  f,„-  instance,  Ilippoci-af^—aiv  apjilieahle 
scai-eely  to  any  other  di-eaH'  than  typhoid  fver,  as  Wnnderlieh  spe- 
cially has  shown.'  With  the  inereasiiijr  impoitaiiee  of  anatoniie  investi- 
iration,  Spi^rclius  Willi,,  and  .Morjrajr„i  as  ,arly  as  the  sevnteenth  and 
ei-hteenth  eeiitinies  made  reiH.rts  of  i)ost-mortem  examinations  that 
unduiihtedly  indieat.d  typhoid  fever.  Clini,.:.!  ..l.s.Tvation,  however, 
<'mld  not  yet  he  l.rnii^ht  into  perf-ef  aee.,nl  with  the  anatonue  eon- 
ditions  at  this  time:  the  .linical  and  th..  patholo<rie  de>eriptiuns  often 
.hd  not  wholly  eoineidc.  The  diseri.nination  of  the  tvphoid  fevers  from 
pla-uc,  malaria,  an,l  a  nmnl.er  of  >cpti,.  pn.eesses  was' jrpadnallv  learned  ; 
l"it  imtd  within  .piite  a  rccnt  period  typhoid  fever  <.ontimi..l  to  he  eon- 
f-Miul.Hl  with  typhus  f.v.T  and  relapsinfr  fever.     Less  sitrniHea-K-e  shonld 

lie  attaeh.d  to  relapsinir  I'cvcr  in   this  eonncrtion.  as   it  nrs  less  e.,m- 

moiily  and  i>  confined  to  a  more  eireimiserihed  area.  Tvphiis  fever 
enn~titnt..l,  however,  a  .erions  ol.sta.'l...  ..spe-iallv  in  KiiLdand  an.l 
'■ '■■'ii'v,  the  eonntrio  f-om  which,  at  the  r\„M'  of  tlu-  eij.ri,t,H.nth  and  the 
lieirnminur  „f  the  ninete,.nth  (rntnri.s.  th..  most  snl.stantial  impnises  for 
the  development  of  our  kn<.wi(.<luc  of  th(.  dis(.as(.  emanat.^i. 

In    Fninee  at    the  he^-inniiiir  "f  the  nim'teenth   centiirv  the  anatomic 
Ic-inns  of   typhoid   fev..r  iMvaine    o-i-a.hially   more    <.|eariy   un.h.rstood  ; 

'  (.■■.-.■/,„■/,',■,/,,■  M,,t„;„. 


i: 


mam^^m^s^:.<s^Ei 


IS 


ryrii'iii)  ii:yi:i: 


liiil  tor  :i  liii'i^r  time  tlic  iilr:i  wm-  iiol  ;il(;iii(lipiii'(l  tliiil  tlic-c  loimis 
l>(liiiii;ic|  :i-  Will  to  tlic  (li-i'a~i  tiial  \\v  kiiuw  tii-dav  as  tv|ilii)iii  fcvci',  a- 
tn  all  nf  ilici-f  I'diiditiiiii-  kiinwii  vai'iiiii-ly  as  war-typliiis,  starvation- 
ty|iliii-.    c  :iiii|i-ty|iliu-,    ami    -iinilar    ilcsiirnalinii-,    all    iit'    wliicli    wen- 

even    at    lliat    til oii-iilciiil    iniita^'iuu-..       In    Kiij,r|anil.    mi    the    ntlicr 

liand,  wliiTi'  ly|iliii-  \\\r\-  hail  always  liini  |irriliiiiiiiiaiit,  il  i-mild  imi  for 
a  Imiu  liiiii'  lif  iiiiilri-tc"«l  why  |)ii~t-iniii'icin  cxaiiiiiiatiuri  in  llic  ca^c-  i'l 
(|iii-tiiin  only  I'Ncrptiunally  di-flo-cil  tlir  lesions  dc.-ci'iliiil  with  siicli 
driail    hy    thr    l''rcnrh    |iliy-iciaiis. 

In  i-'ianiT,  I'lo-t  '  had  a- rally  a-  1  SO  (  diinon-tr;it<'d  tliat  the  tvpliiiiil 
frvir-  wi'iT  I'liii-tantly  a—oi-ialrd  with  drtinitr  intestinal  lesion-^.  His 
eoiii'lii-ion  was  lia-ed  ii|)on  the  nnii-iially  laiye  ainnimt  id'  aiiatoiiiic 
material  thnii-heil  hy  •_'(•(»  aiilo]i>ie-.  Hi-  views  were  niateriallv 
enlarged  ii|>on  liy  I'elit  and  Serre<,-'  who  ealled  attention  to  the  faet  that 
undei-  the  eonditiiiii-  in  i|iie-tion  e-peeially  the  Inwcr  |Mii'tii(iis  of  the 
small  intestine  were  iinnKed,  and  tliat  the  le-ions  slioilld  lie  eiiii- 
sidei'ed  -|)e<iiie,  prohaldy  re-nltiiii.'  tVom  the  aetimi  of  a  siiceial  |ioisiiii. 
Althoii<.rh  liretonneaii  '  fiirtJier  deteniiineil  ~iiliMK|iieiitlv  that  the  intes- 
tinal mneoii^  nienilii-ane  it-elf  was  not  the  seat  iif  the  moriiid  ])i'oeess 
ill  "|iie-tion,  lint  the  lyni|pliatie  a|i|iaratii-  ol'  the  intestine  iiiiist  lie  enii- 
sidered  the  lia-i-ot'  the  <li-ease  ;  and  alter  him  Liiiiis  *  estalili-liiil  most 
clearly  the  relation  lietwcen  the  intestinal  lesion  and  the  jri'iieral  efin- 
ilitioii  ;  althoiii_rh.  tinally,  Choniel  '  de-erilieil  the  anatomic  lesions  mi ife 
fully  and  the  clinical  manifestations  with  -pccial  elcaniess, — an  alisiilute 
dini  Tcntiation  lietwcen  the  ty|iliiiid  diseases,  es|iecially  lietwecn  ty])li(iid 
and  ty]iliii<  fever,  could  nut  lie  made.  I'ndcr  the  influence  of  those 
frri'iit  Frencli  elinieiaii>  it  was  almost  universally  liclii'vi'*!  that,  altiioii^li 
ty]>liiiid  liver  wa-  invarialily  as^ociatcnl  with  intestinal  lesiims,  it  could, 
Imwevcr,  lie  directly  contajrious,  in  the  same  way  a.s  small-jnix  aud  other 
acute  cxantlieinata. 

At  till  heirinninfr  of  the  niii(>te<'ntli  century,  nt  a  time  wlicii  tlie 
I'rench  and  .ne  Kiijrlish  were  nnalile  to  reach  a  clear  tinderstaiidinjr, 
in  spite  of  exact  clinical  and  anatomic  oliscrvations,  remarkalily  definite 
view-,  a|t]iroximatinir  tlm-e  of  the  pre-eiit  <lay.   had  been   express(><l   in 


I   M.'h'i'hir  rHniriC  pnr  l'i,lisrrriifin>i  if  I' mirirln i-r  ilrs  cnrps,  etc.,   I'liri.-.    Is04. 

'I  Tra,i:  ,1,  h,  ti:rr,,;,i;rn.i„,\,;,i;ri'i,i,\  ]'uri>.   IM:'.. 

'■■Ill'    l:i   cluiiiiiiil.Tiir,  '   .!,■,•//.  ;i!i,.    </,-    I,,,,/..    IM-Ji;,     Tim    iiH (lolliicnt.'rit' 

(ft  f^'.H,,,  lu'tiiorrliM'^ic  iilniT.  ftiruiu'lo)  wih  jirojui-ol  t»v  liri'tniinciiu.  mid  if  \\;t- 
buli-i'i|iii'iitly  liiriu'ly  I'liiplnyi'il  tiy  tlii'  Krriicli,  e-|»'('i!illy  liy  Tnm.-.-eau. 

*  /i^r/irrr/irs  finr  I't  /im/ni/ir  mtiiiift'  s"//s  /<  s  n<>)ns  'h  >]iisti-^>i')itiril*'.  fi'f'i'C  p"trf-h, 
ailjiiniiiiUinv,  iti..   Paris,  18i;;i. 

^  /,,v,,„.v  ,/,■,•/;»;,,//.•  ,„/,/;,-.       Tmni'  i       Ku'rrr  f„nl,,„,l,-     I'.iri-     1H:U. 


r-'-jrrrriiriiTiirwTnrnriWffTririTrT'T^r^^  * 


i:riiii.i)i;Y. 

(1.  iiii:iiiy.  I'ndcr  the  liiciiri'  c  f  1  Iil<Kiil)r:ui<l,'  who  juiMi^licd  liis 
iin|«ntaiit  work  in  1S1((,  typlms  uiwl  typhoid  ^\^\^^\•  hv^r-.m  to  he  (iiiror- 
.iiilalcii.  Thnv  were,  as  it  a|i|>car-,  los  cxaci  aiiatoinic  and  ciinical 
data  than  iriicili^ciit  tinpiiir  coni'cinion-;  wiiicii  ]Miintcd  in  tho  riidit 
diici'tioii. 

It  \\a>  riot  nntii   the  fourth  and  lil'th  drcado  of  tiic  ninctcfntii  rcn- 
tiiry  that  tiic  (hlVcrcniTs  of  opinion  were  hai'nioni/(Kl.      At   tin's  tin'.c  it 

' I'lif  po-sii)lf  to  MTUiT  nvncral  nt-oj^nition  of  tiu'  nitlividnalitv  of  tiie 

two  <liM'as(.<,  aTid  tiicnhy  to  place  tlu,"  I'ti.iloixy  „|K.n  a  linn  fi)inidation. 
To  two  Aiucricaii  physician-,  iicihard  an<l  I'cnnock.-'  hclon^rs  the  credit 
t^ir  havinir  finally  e-tal)lishe<l  the  ditl'erentiatinii.  '|'hc  cit'anie-s  of  their 
ditl'crcntiai  diairno-tie  statements  is  notewortliv  i'or  their  time;  as  lur 
iii-taiice,  tiieir  ai)ility  to  di-tin;;ni~h  the  ro-inijons  cxanthem  of  eaeii  dis- 
ease, (^'iliard  and  I'cnnock's  eomininiication  was  snppicinented  ;nul 
timplitied  l)y  mimen>ns  pa|>ers  from  <;ernian,  French,  and  Enirlish 
source-,  a mon<r  wiiidi  tho-c  of  Stal.eroli  '  an<l  Stewart*  ni.iv  he  nim- 
tioiied,  and,  ahove  all,  the  opinions  e\])re— ed  liy  the  e-ift*^!  Louis   in  the 

second  edition  of  his  tainou-  work  in  1S4I,  in  which  he  nn litionally 

• 'I""    til"'    i><'\\'    doi'triiie.      The    names    of   .leuncr,    .Mnrchi.-on,    and 

<irie-inj,rer  are  as-.ociate<l  with  further  jrre  it   ;Mlvanees  leadinjr  up  to   the 
views   held  at    the   pre-eiit   dav. 

Althoiiirl,  it  was  dillicnlt  for  phy-ieiaiis  to  reiioinicc  the  doetrino  of 

nnity,  they  adhered,  after  its  ahandom.K'iit,  to  the  ( ception  of  a  dose 

relation  hetweeii  typhus  and  typhoid  fever.      These  views  have  not  been 

entirely  eliminated  from  s o  moclern  descriptions,  and  cannot  he  dis- 

lodircd  from  the  minds  of  some  clinicians.  In  (Jermany  the  crwiit  of 
hivinir  reco<rnized  fundament  il  distincti(ms  hetweeu  the  two  diseases 
helon^rs  to  (iriesinp.r,  and  (-ptn-ially  to  Liehermeistcr  in  his  dassic 
<ie-cription  of  typhoi.l  fever;  and  the  author  of  this  article  hdievcs 
that  he  went  a  step  further,  in  the  third  inlition  of  /JcmM.-<,;r><  Hnnd- 
A"./(,  in  frivinjr  expre-sion  outside  of  (iermany  to  this  imix)rtaiit  dis- 
tinction hy  pla.'injr  sp,,tted  fi.ver  amonn.  tlie"a<aito  exantluanata,  and 
m-ently  demandin^r  the  ahandonnient  of  the  designation  tvphus  fever 
altoiivther. 

Historic  Considerations  upon  the  Etiology  of  Typhoid 

Fever.— The  <liscussion  of  the  etiology  of  tyi)hoid  fever  will   he  pre- 

'  r.h,-r,lr„  n„sf,;-k,;„l,,i  Tiijiln,<.  Vienna,  1810. 

■'    -On   tb..  Typhus  Frv.r  which  o.vurr,;.d  at   Pliihuh.lphia  in   188.1,  >h,.w,n- the 
l>M,„.f  .,n.  h.,w,.,.n  I,  ,.„,!  I)„thi,.n„.rilis,-  ..|,„,,..  y„„,.  ,,/.</.  Sci.,  voU.  xix,  und^x, 

^  Diililin  J„i,,-.  M,,l   X.-;..  v,.I.  xiii..  1H:!«. 

*      h:,l;„h  A/,.,/        ,,..,,/     v........  I,,,.  ;S.,  ■;j.'.; 


20 


rviii'iii)  I  i:\i:i: 


(-.-.liil  \n   -c'liic  lii-I(.ric  < -Hlinitioii--.      'I'll'-.'  uill  'leal  with  <>\u'  of  the 

iii..-t    iiitiic-liiii:   (■lia|it<'i>    ill    till'  lii-Ioi-v  dt'  the    iiLliclioii--  di-cMM-,  :in<l 
liiitiinilv    will    ntlc<-t    .ill    ol'    the    (loiil.tr-    ami    iiiiiirtaintif.-    that     were 

HI,. itrrcl    in    the  .IcvclMpiiicnt    nt'    ihr   Uimw  l.il-v  ul'    the   iiatiiiv  <.!' 

til,.  ,        ,„.  ;iiiil    it-   (lilli  lejitiatiiiii    t'lmii   coiKlitidii-   Hi|iirliri;illy   n-ciii- 

liliiii:   It. 

}•  ,i(c<i  x'ariTlv  Itc  ciiiiiha-i/rd  that  in  tli( cailic-t  tiiiu-.  licfuiv  thf 
cliiiiial  |.icliirc  of  tv|ilioiil  hvir  liail  n— iiiiiiil  il«rmitc  -liapc,  the  lii'wt 
\aii<il  aii'l  vau'iii'  tailm's  were  lucikiil  iiibhi  a  ctiwli.^ic.  I-;-|)fiially 
:i|.|>aiciil  i'niin  the  (li-fn|)tii)iis  i-  the  ■ntliitiirc  iiMiltin;:  t'l'om  cim- 
llimiiliiiL' I'th'i-  ili-ta-f-  with  t\  |ih(i'(l  f.vcr.  With  the  roriiiatiiiii  <>t'  ;i 
l)cttcr  cliiiical  r(inri.|iliiin  nt'  typhniil  ti'Vcr_  iiiiii-c  (Irrmilc  ctiiilduic  \  icws 
al-.i  ai(i-r,  anil  thr-f  iv-ulli<l  in  lh<'  (l.iririiic  nt'  |iiilrcfactinn  and  (Ici-oin- 
iMi-iiion,  which  ai>|)caiiil  nr\t  anil  la-tiil  tor  a  lun^^  time.  At  tir-.t, 
i-athtr  I'-cnciiil  and  n^t  -|i<iitic  ]iriH(><("s  wnc  had  in  mind  :  )iiitiid 
divii]n|i  i-iticn  in  ti:i>  rai-lli  and  c'l.ntaininalioii  ><{'  tlu'  air.  which  were 
hclicvcd    tn    hr  .-|.cciall_v  clTcrtivc    in    >niall   dwcllini:-,    liidi:intr-hoiiM's, 

:iiid  other  | 'Iv  vcntilatc<l  apartincnl-.  and  n<-ca-ionall_v  al~o  dccoiniMoi- 

tion  of  iirticlc-  of  food  and  driid<.  To  all  of  thc-t'  the  indelinite  con- 
(•(•|i;ioii-  of  eold.  overeNcrtioii.  and  emotional  (li.-turhamrs  were  ailiKil  a.-* 
of  (-i)ceial  im|(oiI:mee.  ami  at  time-  a-  even  alone  siitlieicnt.  W  ilh  >ileli 
factors  in  vaivinir  eoinliination  etiolo^ie  lhe<irics  were  formed.  The 
names  fchris  |intri<la.  imtrida  nervosi,  fievre  ataNi(|iie.  etc.  (  W  illisiil-. 
\\inlrinLdiam,  Ti-sot,  I'incl),  are  the  otV>|)rin^  of  a  period  w  ho.-e  iiiHn- 
ence  was  aiiiircciahle  iiniil  w  ithin  rc'-ent  time-. 

The  putrefactive  theorv  had  di-tin^ui-luil  adherents  mitil  Iteyoml  the 
middle  of  the  nineteenth  century.  It  re<'eive<l  esiMfial  development 
at  the  hands  of  Mnrchison,'  di-thi^'nisheil  for  ills  stiidie-  in  colinection 
with  the  infections  di^'ax'-,  who  ^--ave  the  disease  the  name  of  pytho- 
pilic  fever,  and  hy  reason  of  his  ^rrcat  ])er>onal  authority  and  aj>|>arently 
exact  observations  exeitisl  a  protoimd  and  la^-tinjr  intlnence  not  only 
upon  hi-  coimtrvmeii,  hut  al><)  npoii  physicians  in  other  countries.  Mis 
view-  are  repn)duced  in  the  snliMipient  air,  soil,  and  water  tliem-ies ; 
and  althou^di  tliev  are  replaced  to-day  hy  more  accuiiite  knowledjre,  they 
led  at  the  time  to  the  adoption  in  Kutrland  of  extensive  pnictical  meas- 
ure-, which  mav  lie  considered  as  constituting:  the  foundation  of  a  lar^re 
part  ot'  modern  hyirieue. 

Murchi-ou  con>idcr.Hl  as  esp(K'ially  dan^renms  tlie  deeompisition  of 
orL^anic  siil)>tanees,  ami  ]>articularly  that  of  human  fci'al  matter.      'I  hoe 

'  S.r  lii-  U.ll-Uli..w!l  w.Tli.   .1    Trnifi:<e  .,»    f/,r  <\.liti iiili'il    Frrrr.t  >,J    Urnit  lintalii. 


V*-" 


Krioi.oay. 


21 


IIHlc|Kll<l(tlllV 


itfMl 


•il> 


times  the  :iil 


matter,  aiu 


ll^eMM', 


lie  lielieNcil   |.j   lir  ot    tlMIII-el\i-  i:i|ial)le   i.t'   ;;i\iie'    (>lii;ill, 

<.f    llie    |ia'ieii(     ami     (iiit~iile     it'    lii-     liciily,    to    ,j)e    ( iiatlirallv    elieirii(  ) 

|M.i-i,Miiii~    -iili-iaiiee-    jieiieiatiii;:    typlidiii    lever.      Ill    li!-    large    work 

:iimI    ill  Miaiiy  iiidiv  iiliial   |iiil(lieatiipir--    Miirelii-oii  \va<   al)le  to  t'ortit'v  liis 

leieliiiiL;-  H  itii    iiiimerniis    iiiii-tratioiis   of  eiidemies   and    is( 

At  liiiie--  tile  di  iiiiviii;:-uater  or  an    artiile  of  lixid,  at  utlier 

't\'  dweiliiiir-niiiiii'  ami   >iee|>iiig-i<Mini-,   \va>   eontaiiiinated   with   jintrid 

>iili-laiice>  le-iilting  iVoin  tile  dee()ni|M)~itiun  ot'  liniiian  feea 

lliil~  Ijeeaiiie   tlie    iniiiiediate   lailse  lor    tlie    de\  eli>|iiiient    of  the   d 

lli^  a—oeiate-  and  >iieee,->ors  lollowed  the  same  line  o'"  tlioiii,dit,  witlioiit 

the  addition  ot"  aiiythiiiir  new,  so  tliat   their  etioloirii     iiive-tiL,Mtioiis   and 

le|ioits  Were  (|iiite  llliiliimi  and    e\  en    ,-eliematie.       An  advance  a|(|H'ared 

to    lie    1 lewilh    the   e\ |K'iiiiiental    inve>tij.nitions   of  Stieh,  and  snl>-e- 

(|iienlly  of  I'anum,  which  aroii-ed  great  inlere-t.  'I"iie>e  observers 
lielieve<l  llieMi~eive-  aMe  to  ilidlice  typhoid  li^ver  liy  the  iiitlodnetioii  of 
putrid  -iili--taiicis  into  tiie  liodies  of  animals,  and  tliii-  to  have  e-tal)- 
lidied  tlie  entire  ^ll^ject  upon  a  firin' t'oiindation.  It  will  he  seen  later 
that    their  eoneln-ions    were   Imsed    n]M)n   a    fallacy 

K\cn  hetlii-e  the  time  o|'  .Mnrclii-oii,  under  the  iiiHiieiiee,  it  is  true 
of  the  ini|>erfect  ditlircntiation  of  typhus  and  Ivjihoid  tever,  a  view 
wholly  o|)|)oM'd  to  the  decoinpo>ition-the<iry  had  arisen,  nanielv,  that  of 
direct  coiita<rioii.  It  was  c-pe<ially  the  great  Freneli  clinicians,  Leiiret,' 
Bretonnean,  and  (icndron,-  who  maintained  with  great  positiveiie<s  that 
typhoid  fever  wa-  ca|)al)lc  of  imme<liate  transmission  through  the  siir- 
loumling  air  from  the  sick  to  pre<li-|)OM'd  individuals,  and  that  tins  was 
by  liir  the  ino«t  I'oinmon  mode  of  origin.  Trousseau  suhscvpientlv 
also  warmly  defended  this  view,  and  undertook  to  ~np|Hirt  it  with  strikin<j 
illustrations. 

'Ihns  two  views  prevailed  eor.fem])onineoii-ly  for  a  time,  the  deeoni- 
lioHtion-theory  and  that  of  direct  tmnsmis>ion,  and  frc<inentlv  eominj? 
in  dirtH't  antagoni~m  with  each  other.  Hradnally  an  intcrme<liate  pwition 
was  reached  aiirl  held  f^r  a  long  time,  whieli,  while  admitting  the  diri'i^t 
li;m-iui"ilpility  of  typhoid  fever,  at  th(>  same  time' accepted  either  as 
predominant  or  e(|nal  in  imi>ortanee  or  as  suhordiiiate  the  sj)ontaii(^)US 
'•  luiM-matie"  mode  of  development.  Kach  of  the-e  two  theories  no 
doiilit  contained  some  ohjective  truth.  To  Miir.  hi.-oii  and  his  disciples 
hcloiigs  the  great  <redit  ol'  having  <'allc<l  attention  es;,eeiallv  to  the 
d  inger  ironi  the  fecal  di-charges  of  the  jiatient,  although  perhaps  not  in 
the  sense  of  to-day  ;    while   those  who  l)elieve<l  in  the  contigioiisness  of 

'  ■■  Mi'ni.  Mir  lit  cl.itliiniti'ritc  A  Nanpy."  Arrh.  pi'ii.  ,lr  vii'it..  Scr.  1..  xviii. 

'  1  -■;:::;_  :::rn:.s  .M-'.  ;■,,■.-,-  au  V  <-ii  wi-mj>  u.-  i'imtraii  tiu  Lnir.       i '>'/■'.,  .Nor.  i.,  xx. 


/■)  riniiii  1 1:\  1 1: 


till-    (li-i  ;i-c,   u  ln(  li    -nlj-((|lli  lillv     llkc'wi-r    jilcixnl     ili-lili:il>lc,    |il;iiii|    llic 
|>('i'-iilial   inllili  me  I  >!' I  III'  ji.il  ii'iil,  t  111'  \  II  u   i\\a[   t  lie  |i<>i-ii||  ciiialiili  i|   tlurii 


mil.   Ill  till'  liiii'L;ri'iiiii 


■11,11-    ill' 


liail    lii'cii    -iillii  ii'iitlv 


I  Tii, 


i|     li>l'     ilinlli.'    till'    w  111, II 


a-  ri'-iivi'ii  till'  |i,i  iiiiilatiiill  d'  llir  \  iru -,  in    j^iiiiial    corri'il,  -ill!    In  M 


;il     tllr    |ilt'-illt     I 
wrri'   a-    I'lillciu- 


las.         Ill-     rollrl 


ii-i,,ii-,  iiiiiaikaMv    aiiili 


I'ol'     III-     li 


r\l,l„,iii  liAcr   raiiiiiil    il('\c|i,|i    -|n,|itaiiii,ii-ls   ;   cm 


ca-r   (,i  i:;iiial('-    iiiiiin'ijialrlv   tioiii    -niiir    aiilii'filciil    ca-c, 


'I'lii-  i\  i,li,,l>! 


|M,i-i,ii  1-  Villi  raliil  li\  till'  ualiciit  Iniii-rll  ;  il  aillnit-  i-|i(iiallv  ^i  llir 
.-t  1,1,1-  w  iili  \\  llir  1 1  il  i-  I '\  an  la  I  I'll.  It  t  liii-  ilr\  i'l,,|i-  imt  oiit-iilr,  n-  M  iir- 
I'lii-i'ii  ami  III-  ili-i'i{,lr-  l,i'lir\  III.  liiil  wiiliin  ilir  lii,ii\  i,|'  tlic  tv|ilii,ii| 
jiatiilil  ;    anil    il     i-    im>I    tlir    |,ii,illii  t  ul'   iinlillrirlit   ^ciirral  iIi-<'iiIII{k  ,-itii  ,|| 

nil!  -|ii(  ilir  acti .  ilv.    itiiiiil 


,|    111  al  liianrf.   I, lit   all  ;::;rllt   i,|    -linillr  i  il  Ii'iil 


('\  111  \M  III    -II   lar   a-    tn    run   n 


Irr   thr    iiiti'-t 


111'   a-    till'    iiiiiiiiiiiatc    iilacc 


,1'  I'lijiii  I'l'  till'  i,i,i-i,n.  in    till'  -aiiir  wav  a-   llii'  -kin   iicrtiirin-  a  -iinilar 


liini'tii,ii  Willi  ii'lalioM'ti,  till'  |,n-liili'  nl  \aii 


,1a.      .\l-i,  !l 


till'    tr;!n-nii--iliilil\    ainl    tli'   lai,  iliilitx'    nl'   i'nilli 


till'  ri,llri'|,tli>ll  111 
■I'    "!t'\  rlii|inirllt    nl    till' 


I" 


iiit.'ilnni    in    lii-   ili  tiiirtlv    ('iKiiH'iatril    vii'W    that 


a    iiiiiiinial 


aiiH'Uiit    ilii'i'i' 


,t'  i-   -iiriiririit  ti,r   till'  coiixcxaiiir  nl'  till'  ili-ca-c  ami   ii- 


I'lirtl 


n  r  I'Mrll-li'll. 


W  illi  li'i^iial  ariiini'li   UmM    iTarhcd  the  I'llllilaiiii'lit: 


(•i,iii'lii-ii,ii  tliat  II  \M,nli|  iiinliiiilitrilly  1,1'  |)i,--il,U'  to  |il'i'V('iit  the  ^|ll^all 
i,t'  till'  ili-cM-i'  it'  111.  iliml-  I'liiiM  lir  i!i'\  i-i'i|  i'a|>alilr  i,t'  rcinlnini;  tlic 
int'crtiuii'^ -tiiiil-  iiiiiiii'iinii- ;  it  iiii^lit  cv  rii  lir  Inipi  "I  tiiat  as  a  I'oiilt  i>t' 
a  li'jii]  a|i|>lirati',ii  ol'  siiili  iin-a-iiiT- 


111  cvrrv  iiiiliviiliial  (■a>(' 


till'  lii 


ilil  111'  w  111, Ilv  iTa  lii'ali 
l>iiilir<  i,l,-i'r\a 


ii<  II  ti,i'  a 


11  liinr  iiiii-t  lie  cuii-ldcii'il  as  masterly.  lit- 
is u  iiliiiiliti-illy  till'  tiiiiiidrr  lit'  till'  ],ri'\ailiii^''  view-  ii|h,ii  tlic  ctiiilniry  ot' 
tyjiliiiiil  ti'Vcr.  Ncvi'illii'li'",  till'  patli  liy  wliiili  mir  |>r(-('iit  (•(iii('(']itiniis 
liavr  liii'ii  rc.'icliiil  t'lilli  wi'd  a  Imii:  ami  iiitiiratr  cuinvi',  in  cDiisciiiK'nci' 
ot'  the  iiii-lcaiiiiiir  ami  nli-triictivi'  intliiciici'  of  cariirr  tiicoiii's. 

.Milioiiirli  till'  iivtlmiri'iiii'  tlicfirv  of  Miirrlii-mi  \\a-  jriiKlnallv  tiis- 
planii  iiy  iiiat  i,t'  tlir  -]ii'i'itii'itv  nl'  tlic  ]M,i-iiii,  tlic  (|iic-tiniis  as  tu  tiic 
iiKiiic  of  lii— ciiiinatiiiii  ut'  tlic  latter,  tlic  (icvclii|)iiiciit  of  tlic  ty|ilu>i(l 
ft'vcr 
(iiic-tiiins  t'liillicr  a-  tu  tlic  iiitluciii 


III    inilivKlual    ca 


-C-,    ill    cmlcinics    ami    cjiidcinics,    tiic    iiii|Mirtaiit 


it'  climate,  of  season,  and  of  iocalitv 


illtel|iii-cd  jrreat  liilliclllts  to  tile  IHiiLTe-- of  i<m)\vlc<|i.'e.       Too  fl'cijUeiltly 

jirevioiis  association  of  the  jiaticiit  witii  otlier  ea-es  ot'  ty|)iioid   tcvcr  or 
tiieir  liiscliari^es  could  not   lie  demonstrated.      The   [iidiialiility  or  }M)ssi- 


'  ■■llii  Inti-tiiml  Fc 
'T   K--.  ntiallv   ('"iitii 


It-      M.'ilr    nf    I' 


n'piiL'ati"!! 


I.a„.;f.  IS.-,r,. 


Intr>liruil 


It-     M.'liL'     i.f     1' 


roi,iii;ati"n.      f' 


ti'..    /''('/.,    \K'>'.>.      "Un 


l!i-:-'i:,M!     K. 


'*--^  ' 


i:  I  I'll. IK,)-. 


23 


liilil\   of  I  i>iil;iiiiiiialii>ii  i.r  Mrli<  Ic- 


.r   U<,„\.  of  <| 


I  Illkini^-WMllT,   Mill 


loll 


-llli-l.ll|CI'~    U  I 


til    tl 


IC    IHll-llll    MIIIMliriK 


I     Ilk. 


w  1-1'  iHil  mI\\:i\  «  ail(<|ii:ilc. 


Iii-li;icl    III     iiHUf    i:iii  I'lilly    ;inal\ /.iiii:    llii-r    rninlitiiiii',    tliiy    uiic 
linii/cil  111'  wIhi.Is    ii^iiuiiHl,  iil»vi<iii~lv  tu  llir  ^'ical  (li~;i<lv:iiilat:r  nl  tlii' 


-Uli|i 


t.      SliiiK     ua-    liinrl 


(il    nillicr 


liiwaid    iiiiiir   L'liicial    iiiiiililii 


tiiwanl   iiiiiiiii-I.iiiri  ~   aiiiiil  uliirli    llic   |i<ii-iiii   ^iiiiiatcil   liy  llic    [laliiiit 
ami   ili~(liaiiriil    liniii    liiiii    rniilil    !«■    t'lii'tlicr    ilt\  iIhihhI    iiii|i|Miii|(iilly 


am 


I    III: 


liii    il^    arllNllv,  III    uiijiT    -iil)-ii|ilrlilly    III   j:alli    ciiliaiiic   iliulfl' 


tli\iiralilc  iiimliliiiii-   ii.lu   tlir  liiiiiiaii  ImkIv.      In   llii-  \\a\  (-iiciiallv  tli(,' 


(M I  III  laim 


til  II 


■till  a-  til' 


ir|Hi-itiirv  ami  till'  |ilaic  ul'  ^.i-iiirialinii 


il'    llir    |iipi-iiii    lit'    ly|iliiiiil    It 


'i'llC      III' 


tlial    the    |Hii-iiii    licit' 


iiiiilriwciil  |irii|)aL;atiiiii,  iiiatiiratinii,  ami  iiiiilti|ilii:iliiin  was  iiumi'liiij 
until  tinallv  llic  iiica  wa-^  cvnlviii  that  -inli  an  iiiliiimiliatc  -lap'  nt  tin- 
|iiii-iiii  \va>  the  nilc,  and   |h>" iliiy  iniii-iicn-aliif,  in    the  ilis-t'iiiinatioii  ut' 

\\  lilmiil    t'rVil". 

Sn|i|iiift  tor   tlicsc  views  was   lliiiip_'lit    tn   lie   (iinml   "ti    rctni-iM-ciivt' 
(ili-nvatiiiii    in  tlic  fmlcinic  iihmIc  ut'  ilis-ciiiinatiuii   ut"  typliiiid  t'tvif,  its 


II  i-i~lfiirc  III  iTi'tain    jiiralitics  ami  (■iicnin-i  rilicd   ai'cas,  ami   al-u  in  tin 


a|i|iaiiiillv  ili-linctivi'  uliMTvatiuii    that    in    nt^iuns   in  wlii: 


•h   the  di-(a-(' 


I' 


ilcd  the  lii-t 


(■a~('s  aiiiK 


I'P 


•aicHl  iil'tcn  wlici'c  r\t('ii>ivi'  cxcavatiuns  ut' 


caith  were  hcini;  made.       I'liis   luiali/atiiin-theurv  has   nut  liii'ti   wliully 


dulled 


•veil    at    the    Iile-ell 


It    dav.       I 


II    one   III'  alio 


ther  t 


urin   It   sti 


nialelially  mllileliees   etiuluirie   eiiiiee|)I  iutis 


I'liis   tlieurv  ut"  luealizatiuil 


allaimd  its  liiL;lie~t  deiri'ee  ut"  develupineiit  ill  the  tiiiiiuils  du<  trine  of 
Hiilil  and  ut"  I'etleiikul'er,  ut"  the  ii'latiun  lietween  the  ^ruiind-v.ater  and 
tlie  develu|inieiit  ut"  typhuid  t'ever.  Hiihl '  elainied  to  have  made  tlie 
ult-ervatiiiii  that  tiie  iiiurtality  t'ruin  ty|)hoid  t".'Ver  in  Miinieh  fe<;iilarly 
(■xliiliiteil  tliiitnatiuns  eorresjiundini;  with  tlie  varyiiii;  K'vel  (it"  tlie  j^roniid- 
walir,  Ml  that  when   this   k'vel  was   liii;li   the  muiialitv  was  feinarkablv 


1, 


uw,  aad  rlri'  rrrsd.  I'ettenUuf'er,-  n]ion  the  basis  ot"  elahorate  statistiesd 
data  ami  exiiiisive  jueal  oliservations,  tV-ilier  develo|)ed  the  theor^'  of 
IJiiliI,  so  that  at  the  end  id'  the  sixth  and  in  the  seventh  de<wle  of  the 
nimleeiitli  eentiiry  the  irroimd-water  thpurv  \vii8  eunsidere<l  in  ( ierniany, 
and  piiilialily  also  in  uther  eonntries,  as  fiillv  established  fur  Miinieh, 
ami.  by  iva-uii  nf  the  adaptiveness  of  the  statistical  data,  as  applicable 
alMi  tu  uther  liKaiitics  and  cities.      Where  this  was  not  eompietely  so,  it 


i.,  isn.j. 


'Kin  lititrun  zur  Ai:li..l..i;ii:  cUi  T_\|iliii.s  in  Miiiicl»-ii,  "  /<■:/.•.->,,■./.  }iiul,,,,ir.  I!J. 
•  t'lOiir  ijio  Soliwunkiiii!;i'n  iliT  TyphusftiTlilicbki'it  in    Miinchen  von  IH'jO  bis 


ISi;:.'   X,-i/s,-/,r.  /.    Iii,.l,„,ie,    IM.    v.,    1Ki;H.      •Ti-Imt  dii'   Ai'ti..l..i;ie  di'S   Typhi 


'.  isa 


'^•:^'. 


2i 


T)  ril'iii,   I  I  I  /  /; 


v\;i>    iIimiimIii     ill;, I     ;,|     |,,,.|     ;,|,     iiii  ii'M-i'    III     (III'    iiin||:ilil\     \'\i<\\\    tviilioiil 
li'M-r  loiilil    III'   ill  iiii>ii-l  i:ili'<l    in    m-^ih  lalimi    uilli    iiiiii-iliI    i|i'\iii->. 
A  IiImiiil;Ii  till'  -ii|i|Miiiir-  III'  till-  i;iiiiiiii|-u:itrr  lliiiii\    wiii-    iiiialili'    tn 

lunil    Mll\    ill  linili'    I'liliri  liliiill     III     tllr   IIMllll'l'    III'    tllr    t\|ll|iiil|     |Hii>u||,    ,'|||i| 

f\iii  ixiiiiillnl  iiili  ii-l  III  llii-  111  la|i-i'  liiillii  T  ill  till'  liai-k'jiiiMiiil  llic 
timri'  lliiv  iHiiiiir  iiiMiKi'il  ill  till'  i;iiiiini|-\\alir  iIhihv,  iIu'V  aiMniiij  In 
lun  \  ii  u  -    -lill  Miliil    al    llir    |iir-i'iil    liav.  iiaiiirl\,  till'    -|«'i'i(ii'it\   111'  the 

|Hii-iiii  ami  il-  I  ijialiililN   ul    ;^i  ii atiniiaiiil   liiiilti|ilirati'iii.       'i'l  iilli  ami 

crrnr  Wrir,  Iih^M'S  ir,  liliscil  in  llir  lllllliri'  In  lirl'  tliat  till'  [iiii-iili  al'li-r 
|>a--iliLr  llil'iiiiL'^li  a  iini'-siiv  "  pl'iirf-- ul  inalinal  ini  "  in  lliiiailli  iia-'-i'<i 
t'i'iiiti  tiii-  iiitii  till'  linniaii  Imilv .  ImIml.''  riii»l  riiiincniK  ti'an-niiiti'il  llii'iiiit.rh 
llii' air,  mil  i\  tlirmiLili  water  nr  llinuiuli  nlliir  innlia.  Ilic  c^raiM'  nt" 
llii'  |iiii-iiii  riniii  till'  lailli,  il'-  '•  I'xIialaliiMi,'"  \\:i-  liciicvcii  In  lir  I't'tiilcicd 
(lilliiiilt  in  ilanip  uiatliir  ami  willi  a  lii_'li  IcmI  nl' llir  tri'niinij-wiilcr,  for 
llii'  iia-nii  that  il-  liri'ii|iiiL.'-|>iiinl  umilil  lir  iii\  ril  l>\  tlii-  water,  ami 
lIlll-  lie  lilt  nil'  I'll. in  till'  -lliraee  111'  llie  earth  :  W  111  le  W  lull  t  he  level  iif 
the  L't'illlKl-Water  wa-  Inw  the  (ieletelinll-.  Ia\er  nf  earth  Wnlllil  he  iti 
ilireel   enniiiniiiieatiiiii  with  the  alinii--|ilierie   air   lliiiiiii.Hi  the  trrniind-air, 

ami    there  wmilil  tliii-  lie  i Ii-triielinn  to  the  inianalinii  i>i  the  |ini-.in. 

.\|>art  1111111  the  I'aet  that  the  thenry  nl'  I'l  lleiiknt'er  iiinnreil  the 
iiatiiie  111'  the  ty|)liiiii|  |Hii-iin  ami  relanliil  il-  -tiiil\',  it  wa-  rnrthcr 
atti'iiileil  with  the  lint  iiiniii-ii II 'lal lie  ili'-aiKaiilMLie  that  it  lirniit:lit 
>trnni;ly  intn  the  lini 'jiniiml.  althnn'^ih  a-  il  m>w  a|i|iear-  uilliniil  -iilli- 
eieiit  Miniiml,  the  ili— einiiiMtii  ill  III'  the  jmi-nii  lliriHiirJi  the  ^'ii  111  mi-ail' 
mill  theme  tiii'iiii'^li  the  alimi-|)hei  ie  air,  ami  a-  a  re-iilt  irrcjit  ly  clieekeil 
t'nr  a   time  the  -tl|i|\'   111'  nlhe'-  etinliiL'ii'  |iu--il  li  lit  ie-. 

It  is  i'-|ii'riallv  inlere-liiiL'  1"  ciilisiiliT  the  ell'erlive  iilijeeliniis  nf  laelM  r- 
iTici-ler  '  ami  .'-iiliM'r|uriilK  nl'  liieinier  '  in  the  I'miiml-waler  tlienrv  ami  ilit^- 
PfiiiiiiMlinn  ihrnUL'h  the  air,  ami  In  imle  tlnir  ili^i'riiniiiiiliiiL'  sii|i|Kirt  of 
ailnlller  liimle  i)^  ili--eliiiliMlinii.  iiaillelv,  that  t  liiniiL'li  H  iiler-ilifeetinll.  Their 
views  iil.-n  LMiiifil  iiiiliieriius  aillicreiils.  1"lie  trrniiml-water  tlienrv.  however, 
reiiiaiiieil  fur  a  lime  sn  linn  that  in  not  a  few  jilaees  epiilemiolnL'ie  iiive-li- 
^ratinll.-  were  ai|a|jteil  In  it.  insleail.  eniiverselv,  nf  ileihieili;:  etinln;;ic  views 
I'rniii  llie  fail.-.  .\-  late  as  the  years  1><m;  iiiiil  Xxxi  the  author  of  tlii.s 
artirle  hail  -mli  an  iiiilnrtiimite  e.\|ierii'iiee.'  When  he  emleiivoreil  to  trace 
the  e|piilemii'  niTiirreiiee  ot'iy|iliniil  fever  ill  I  laii.liiir^'  al  that  time  —  mnrc  than 
lil.OllO  |M'r-nns  hail  heiii  allaekeil  — In  >|ieritlc  iiiH  I'tion  i\\'  the  water  nhlaimil 
trniii  llie  river  l-]llie.  ami  ii-iil  for  ilriiikiiii:  ami  ilnineslie  ]iur|inM's.  it  was 
tniiml  llial  eertaiii  eirrles  .liil  not  ennsiilcr  il  worth  while  to  take  this  |iij>- 
sihilitv    into  eoii^iileralioii.       I'lie   i:rnunil-waler   tlienrv    \va.s    helieveil    to    he 


'   (i,..,„n,.l,-  .\hln,,..ll,i„.i,„. 

'    \'.,ll:mnn„'s  S,i,„,„l.    U'.i,     V.,rlr  .    IsT:;.   N...   ."iP,. 
I  i.i -rliiii.'Hiii.  "  Miiii-ti-rlii-  uimI  I\!iiii-.|M-  uln'rili'ii  l' iili'rl.'ilijt\  plui- ill  lluiu' 


I.ll'il.ni.  V 


25 


wlmllv     -lllllrlilil     I'l    I  \|iLllll     lllr    c     ijili'lllii'    aini     In    u\  cridliH-    till'    oliji  I'lliili!* 
r:ii-c(l    :i.'.iM].-l    till'   UMlrr    nl'  tin-    llllit-. 

A-   li.i-  liicii   -(III,  mil-  111'  till'  iiiH-t  Viilinililc  :i-|K(|.  ul"  ilir  iluctriiic-i 

111'    lldlil    Mini    I'rllciikiili  |-    i-  llir  <'lii|illM-i~     |il,iii'<|   ll|iiiii     IJic   \il:ilit\    ;ilii| 

till'    |»i\M  r  111'   liinlll|iliraliiili  ul'    I  111'  l\  |iliiiji|   iMii-iiji,  III  \\  jiii  h     I  till  |<  I    .11 11 1 

lii-  |iii|iil-  li.nl  |iir\  iiiii-ly  (liriH'h'd  Miiiiiiii.ii.       \\|.  may  ii  i  ntrni/,.  in  thj^ 

tlic  lniii  iiiiiiri- III'  fill'  |iii-i'iit  view  (if    i    liviii'„'  i"iiitai,'iiiiii.      A-  I'arh  an 

llic   vrir  I  .s  ,' I    ilil-  \  ii'u   111';;  111    III  a--iiiiii'  iinii'i'  i|rtiiiit(i   sliajM'.       Ilcrcr- 

<  inr    mill    111'  iiiaili'    iiiil\    111    ihf    wuik-    (if  von    Itci'klilijrliaii-i'ii,'    \\lii( 

lallril    allciiiiun    in    ijir    t'iii|iii'iii    iicciirrciicc  III'  ('(Kci    in    the  ur^rans  ul" 

ly|iliiiii|  |ialiiiil-,  i-|ii.i,ill\    in  llic  kiilnrys.  a>  well  a-  In  the  ji—  -iirii'— 

I'ul  an.'iii|iN  111'   KIciii     Si, kill. .11','   Fi-('li(  I,' ami  oiliir-  i..  (Icinun-Iiaic 

an  i)ii:ani/(Kl  l\  {iliuiil  ^     i-mi. 

Il  \va-  ri'-crvcil  liir  i'llii'i-ih,'  in  tjic  yrar  l.sso,  in  di-ruvcr   llic  hacil- 

lii-  al  llii'  |irc«<iit  Hay  ililinilcly  rfiiit.nii/.i<l  a-  tlic  raii-c  ul' tv|iliiiiil  fever, 

Mini  in  I  lie  ali-eiiii'  ul' iiiiiliiiiialinii  Ky  cnltivaliiiii  ami  iniMiilaliuii,  tne^tal)- 

li-li  il^  -peeirniiy  uiili  (.'real  i>iiil)aliility.      Aliin.-l  ii lent iea  1  oii'-ervat inns 

Uele    -nl)-ei|lii'iilly    Inailel.y    li.ii.erl     Ki)eli"aml    W'iliielin    Mever,"  who 

Wnlkeil    limler    the    imeliljve    ami    ilileelioii    of     Flieillaiiili'f,     while    the 

llliirii-iiliraili-ni-i|e-eiil.(Kl  hy  Kiel.- \ire  not  at  the  |ire-ei)t  <lav  eoii-i,|eie.l 

iileiitieal   l.y  the  inajoiily  of  haeteiiolojri-is   with    th..-e  of   Kl.erlh.      In 

Kiiirlaml.  Coate-  ami  ('rook ilirnied  the  oli-ervation-  of  Kherth,  and 

al-o   in   other  eoiiniries  ol>-ervei-   were   -non    iiidn-trioii>lv  emrajred    in 

.-tndyiiii,'  the  new  liaeillns  without,  however,  inateriallv  ,i(liliiiir  anvthiii},' 

to  the  kmiwleili.re  of  its  hiolo^ry.      Neither  ( 'oze  and  Felt/  nor  Mara^diano 

'Sneeeeded  in  eiiliival ini;  and  i-olalin.^r  the  |iiitliou'eiiie  ^r,.nii. 

(Jatfky  '   was  tli<'  tii-t,  as   the   iv-nlt   of  a   l.iilliant    inve-tiiration,  to 

lirini:  the  entile  -iihjeet  to  its  |.ie-ent  tinn  foiiiidalioii.      He  perfeeted  in 

material    point-   the   nior|ilio|oiry  of  the   haeilliH,   and   l.v  ineaiis  „f  im- 

inerons  |iaiii-lakiii^r  |..i-t-niorteni  exainiiiations  denion-trated  its  di-trihn- 

tion   and   arian-einent    in   the  oririins  and   ti-ues,  and   finallv  deserihed 

the   method    fir   i-olatiiiLT  it   and  ^ri-owini:  it  in  pure  culture.      Althouirh 

<.atlky  wa-  not  -uece-sful  in  cNpiiiincntally  prodiicinir  typhoid  fever  in 

'  WarrM.  Zrit..   IsTI,      (■.„„, ,;,r,.   ,||.,,    Kli.Tlh.  /„,■  K,;n,/„i..  ,/,,■   l,„lj,ri..l..,i...-hn, 
MijL^.srn,   I.i'ipziL;.  IsTJ. 

~  /;,;„„■/>,  ../  ,/„   M.:/,,-^!  om,-,'  ,.(  Ihr  Vr,,:i  C.uncU  nwl  /.",'„/  a.., ■,■,■„„:(•„»   /!..,,./ 

Nn  i;.  isr,-,. 

■■  \y-/>n,rs  .Ire/,;,'.   iM.  jxvi..  ISTr,.  '  I'rwirr  mnl.   Wm-hei'^rltnfl.  1878. 

'  Vn:-I,..,rs  Ar.-hir.    U,l.    Ixwi.    u,    \\\\\\\. 

«  M^llh.-ilun.in,  fiiis  ,/,„,  A„i^.   (l,s,n„//„itm,„f,:  I!d.  i. 
'  I'lrjiifjtiral  Dixyrrldti,,,!,   liiTliii,  lS81. 

'  Arr/n,-./.  erprr.   l',iHi.,l.  „.   I'hnrmak..   Ii,J.  .\ii,  n.  xiii. 

-  ,•■:■::.■,■',:„,„,,„  ,1,,^  ,;,^,  ^,iis,  i,,-siiii'iiirii^,niit,\  lid,  ii. 


_^.__.aMi> 


26 


ryi'iinin  ii:\i:i:. 


;iiiiiii;il-  w  illi  tli<'-c  |)iiri'  I'lilliirc-,  lir  wii-  :iiili-,  I'niiii  ilic  ccrtiiiiity  imil  tlic 
I'M  ml  lit'  hi-  I  It  111  r  iili-i'i'v:iliiiii-,  r-|M'<ially  iVuiii  I  lie  iniilniilitcil  riiii>t;ini'y 
.if   il-  iiri'liriTlirr  111   ra-r-  iif   (\|(lliiiil   I'rVrr    ami    il>  aliM'llcc   iViilll   lirallliy 

iiiiliviiliial-,  111  fiiniiiilaii'  ilir  tlcliiiilf  ciiiiclii-iun  that  tlic  urg-aiiUiii  is  the 
-|i(Tit'ii-  raii-r  lit'  lyiihiiiil  Irsrr. 

'I'lir  -tiulir-  lit'  (latVkv  \m  rr  liilliiwcil  in  all  cnimtrics  hy  an  cniifninus 
aniMinit  ni'  wmk  with  tln'  t\  |ihiiiil-iiaiilli,  mi  liiat  Lii-cncr  a  t'cw  year- 
a:;iiua-  aiiir  In  inal<c  a  i-nlliiiiiiii  nl'  CiSli  |ia|irr-  mi  tlii<  »ul)jiTt.  Tiii'-i' 
I'liiitlrni  in  i:riii'ral  ami  aiii|ilit\'  in  -miir  ili  tail-  thr  ri-iill-  dlitaimil  liy 
(iatl'kv.  at  liiiii-  |ii-iiiiTiliii-  -kriilii-ally,  luiI  -till  iiinrr  t'i'ii|ncntly  t^ninir 
iiivnml  hi-  \i<\\-.  At  aii\  rati',  at  llir  iiic-riit  ilay  a  rliar  i'iinc('|i- 
tinii  ha-  I'll  n  t'lirniiil  nl'  iIh'  iiiiir|ihi'liii;y  anil  thr  ili'\  rlii]iim'nt  nl'  the 
harilhi-.  ami  roii-jiji-ralilr  i-  kimwii  with  i'i"j;ai'il  In  il-  iirhav'inr  Imlh 
witliin  anil  niit-iilc  nl'  tin  li'.ily  nl'  thr  tyjihniil  ]ialiriit.  XiniiiTiins 
sti'iilr-  liavi'  lii'in  niaili'  wiili  ri'i:ai'il  In  ilir  pn-i'iirc  ami  thr  lichax  inr  nf 
till'  haiilln-.  iii'l  alniir  in  tii.iliail.  hnt  al-n  in  the  livinu'  limly.  The 
nr^ani-ni    ha-   luin    niitaiinil    rrmn    thr    lilnml,  thr    -iilcrii,  thr   -kin,  ami 

till'  ili'jri'tinn-,   r-|ii'rlall\    llir    ti -  ami    ihr   ni'inr.       Our    rr-nit    alnnc, 

whii'h,  a-  ha-  liirii  niriitinmil,  ( iatl'ky  liiilnl  In  -rrin'r,  ha-  imt  yet  lirrn 
allainril.  nann-K.  thr  (lrviln|inirMt  lA'  thr  ili-ra-r  r\|irriniriitally  in 
animal-.  Nrilhir  \<v  nuan-  nt'  tin-  rarlii  i'  i  ni'lr  nirlhnd-  nl'  t'mlinir 
tviihniil  -innl-  tii  Narimi-  rX|iri'inH'nlal  ;iniinal-,  a>  jirarti-nl  liy  .Mnnlii- 
-nii.  Klrin,  Khli-,  I!irrli-llii--rht'rlil,  anil  nthn--.  nni'  liy  imiriilalinns 
with  |inrr  rnltnrr-.  ha-  -llrrr—  a-  yrt  hrm  nhtainnl  in  drvrlnjiinL''  Inir 
tyiiliiiiil    rrvrr   in   animal,-. 


MORPHOLOGY  AND  BIOLOGY  OF  THE  TYPHOID- 
BACILLUS. 

'I'lir  liarilli  nf  Klirrtli.  ill  tlirir  (ii-iliiiary  fnrm,  arc  cnmitafativcly 
>hnrt,  thirk  mil-,  \\illi  mniiilril  rxtrcniitii-,  almnl  thriic  a-  Inii^'  a-  thry 
arr  uiilr,  ami  in  aii-'lntr  IniLrth  onr-tlilril  the  <lianirtrr  of  a  rcil  lilnml- 
rni'|ii!-ili'.  In  ulrrratril  I'lM'!'"-  |iati'lii- ami  innthi-r  |iart-  at  thr  hrii^dit 
(it'  the  -jd'cilic  Ic-iiiTi-  thr  liarilli  tiirm,  hv  lniii:itmliiial  a|i|iliratiiin  tn  nnt' 
aniilliiT,  filanirntiiiis  stnirtni'r-,  tir-l  (Ir-rrihn!  liy  (iatl'ky  a-  "  ]i-rn(lii- 
lilaiiirnl-,"  I'mlrr  variiiii-  rirrnni-ta.nrr- thr  harilli  iimlrrL''n  rhanL'i'>  in 
fmii,  -\/r.  ami  arranLirimnt.  Tlin-  thr  |i-ciulo-tilainrnts  alrrady 
inrntinnnl  will  lie  i'niinil  in  nlij  linuillnn-rnltnrr<  or  <xrl;itin-rnltnrr-;, 
a-  Will  a-  nil  [intatii  nt'  arid  rrartiim,  ^.Tnw  inir  to  rrniarkalily  Innp 
-tnirturr-.      Thr  inilividiial  liarilli   al-n  api'rar  tn  lirminc  iihinipcr  npoii 

rrlatin    and    Iintaln    than    iinmi    aimr    m-    liniilllnii.       ThrV   virld    111>  tl"  -<> 


■.c^  ■■ 


i:Tlni.(j(;v.  27 

[icciiliaritii'S,    liMWcvcr,    wlicii    tniii-t'frnil    to  nilitr   iiiilriciit    iiicdi:!,    in 
;i'<i)r(l:iiic'c   with   tlir   cliaractiT   of  tlic    l:ill(  r. 

S|i,irc-riiriii:itiiiii    was   luriiiirly   iiicdiTcctly  liclicxcil    t<>   take  plarc  iti 

tilt;  liaiilli,  and   tlic  Ijriirlit  luxlics   tliat  liiiliMl  tu  take   the  -lain  l\  iii"  at 


•'IG.  1,  — Typhuiil  l-arjlh:  imi'D's^  i>rcp:ir;iti''n 


till'  rxtrcinitic-   as  well  as   in   tlic   iniildlr  of  tlic   liacilli   wcw  tl ojit 

t'l  li(>  ,-]iiiri-s.  'riii-c  ai'c  at  tlic  iirc-cnt  time  ciiii-iilcnd  a-  dciii  iciicir-, 
alti-iliutaiilc  I'iilicf  to  a  in'dcc-s  of  involiiiion  in  tlic  hacilii  or  a-  an 
artefact  dcvclojud   in   luating  an<l   stainin^r  (^H.    Bnclnicr '). 


-  'i 


Fill.    'J  — Typhoi.l-lmoilli ;    j.urc    riilturo 
with  iiseuilc.-fihinunts. 


Fiii.  :'..-rMili.,j,l-l.iicij|i  Hill;   tliii,-illa: 
stilinril  hv  ;,..ilU'rs  liKlliml. 


Wlicn  ciiltivatod  in  siiitiil)I(' flnid  nuMliu  (honiHoii)  and  oIi^tvc.I  in 
liaii-MiiT-drop,  the  haciili  exhibit  active  si»(,ntaiieoii-  nioveinent,  in  whi.h 
I'oth  tlie  iiidividnal  ivmIs  as  well  as  the  p-eiKlo-filaineiits  |)arlici|.ate. 
'I  Ins   is  dependent,  as    LiWller   lias  denion>tl-ated   liy   -|iecial    inelh(Ml-  <.|" 


I 


^j^mtm^m  m  if  r.i 


'^s. 


TV  rum  I)  i-i:vi:n. 


slaiiiiML'.  u|i"Ti  fill'  ]in-ciiri'  (pf  IhiL^Ha,  wliidi  ari>c  in  larir<'  iiiiiiihcr-,  up 
|i.  l"i  and  ('Mil  -Jd  ami  iiu'It,  fnnii  all  part^nf  the  ^ll^t■a(•(■  of  the  liacilii, 
and  in  ,-nitaMr  |in|iarariun~  can  tVc<|Ucntly  l)c  tlmnd  ■'  laclicd  and  iyinu 
i'rcf.  Sii  far  :i-  i-  known,  anidnir  Ixidic-  rc-tinlilintr  tin  typliciid-hacilln-, 
spontanciin-  innxcmcnt,  tn^cthcr  with  tlaplla  (•an>inj:;  it.  <>ccnr>  cnlv  in 
Uaciilns-^dli  and  I'loscly  related  t^lin-.  A  dillerenee  ajipear-,  licwever, 
til  re.-ide  in  the  taet  that  the  nnnilier  •<['  llaiiclla  attached  I<i  liacilln- 
cdli    is   mnch    ~inaller,    \h-\ws   -tated   h<   lie   neNcr    nicn'e   than    HI. 

Typhi. id-liacilli  can  he  ^Iaincll  with  aiiilin  dye-.  Imt  with  nmiv 
(litfictdtv  than  many  other  palhnjrenic  niicrn-uruani^ni-.  It  i-  charac- 
teristic that  -tainiiiL''  li\'  the  ini  llmd  ot'Cirani  i>  never  -nece—t'nl.  At 
time-.  e-iiecialK  in  nld  ctiltnre-  npini  fcehly  acid  ])iitatii.  the  liacteiia 
exhiliit  -inmLilv  i-etVacii\e  |iiilai-  limlie-,  which  stain  nmrc  readily  and 
mure  dceplv  than  the  remainder  of  the  Imdy  I't'  tiic  haeteria  (H.  Hiieli- 
ncr  '  These  al-o  ale  nnilunlii'dly  imt  tn  he  cunsideriKl  as  -pure-,  as  i- 
indicai.d  li\-  the  I'aet  that  the  orji-.nii-nis  in  which  they  are  cuntained  d<i 
nut  exhiliit  incrca-ed  piiwer-  lit'  resistance.  I'mhalily  the  appearance 
lit'  the  pillar  liiidie-  likewise  i-  rather  to  l)c  referred  tu  an  invuhitiunal 
|iriii.'e— . 

l!\in  thimiih,  a>  is  imaniinun-ly  aijreed  hy  tiie  must  ex|>erieiieed 
iili-er\i  r-,  the  scveril\  uf  an  attack  of  typhuid  fever  is  hy  im  means 
alwav-  pnipiirti'inatc  tu  the  nnmlier  uf  liacilii-  in  the  ur^^aiis  after  death 
and  dnrini.-  life,  and  a-  a  matter  uf  tiict  remarkaiily  few  liacilii  are 
iicca-iiii;all\-  fuimd  in  -e\  ere  ea-e-.  it  is  ".reneiidly  easy,  with  a  little  >kill, 
tu  ulilain  the  |ia|liui:enic  liacilii  frum  the  spleen,  the  mesenteric  elands, 
and  I'evcr"-  patche-,  <-pecially  at  the  lieiLdit  ><['  inliltratiun  and  with 
lici^inniiii:  nlccratiiin.  That  tlicv  can  lie  cnltivated  from  the  liliiud  ami 
the  -|ileen  dnrin'T  life,  tlmniih  with  j^-rcalci'  ditlicidty,  and  alsu  fruiii  the 
dcjcctiuii-   and   tlie  cxcretiuns.    lias  already    lieeii    mcntiuned. 

In  all  "f  thi-e  cuMiieetiuns  it  i-  important  tu  know  that  tlie  liacilln- 
thri\c-  lic-t  at  the  tein|ieratnrc  i\\'  the  Imdy,  aliont  '■\~'^  C,  allhuiieh 
it  develops  va  .  'ly  and  almndantly  al-u  at  lower  temperatures,  a^, 
for  in-taiK'c,  ::i  ordinarv  room-teinperatnre.  Like  the  ina|iirily  ot 
pathoirenic  micru-iir;raiii^||is,  the  typhuld-liacillns  disi>lay--  facnltative 
anair.iliiu-i- — that  is,  it  lives  and  develups  either  with  exelusiun  uf 
owLiin  (Lilmriu-)  urwith  access  ut'  uxyircn — in  the  latter  event,  it  is 
true,  with  trreatcr  enerev  and  in  jrreater  ahnndancc.  'I'lie  cnltivatiun 
<it'  the  liaeillns  can  l)e  etfected  readilv  and  iipun  variuiis  cnlinrc-iiKMlia  : 
upon  Mclatiii,  .MLiar,  lilood— enim,  and  e-pecially  upon  potato.  An 
almndant    uru\\tli    take-   |ilacc  e\  en  w  hen    (he   la-t-named    medinm    j)iis- 

•   i.i'r.  ,-ir 


KTKil.dC  Y. 


■1\) 


liirlitlv  ;ii-iil  rca< 


ti<m.     Tlic  iKicilliis  ex 


liil)it- 


activc  (IcvclipptiU'iit 


IIUlltl|lll<'lltl 


•;(\viM'  m 


laiirr    I-    ri'inlcrci 


(■1)K 


tliii<l~ 
-1, 


oiicciMllv   :ii    l>i>iiiiii>ii  ami   nil 


ilk. 


icnl,   witliiiiit    iiiKliTtriiiiiir    cua^'u 


lati 


ACM   alter   liaviii"-  Kmi   cxihim'iI   liir  a  (•■iii>i<lcralilc  time  to  llic  actimi 


,1'   t!i. 


lacillii-.       rill'   l>i 
it'    tlic    (IcVcl'ilHI 


111    i>   I'fiulcrcil  I 


if    tlic    liai 


ii-tiiictly  turhid   in  i'iiiisc-» 
A    .~liirlit    .~c<liiiiciit    tliat 


(Icvclnii- (111  >taiiiiiiii:  ^c|>a^atc- nil  auntatiiin   into  iiniloriii   iiiinutc  ])u.  .i- 


'i'lial   tlic  liacilli   tliri\c   liixiiriantlv,  iinilcr  favoniliic 


(liti 


III  articlc- 


if  i; 


-titutcd  dl'  till 


-iil)>taiicc~  naiiicil  or  nt'  rclati 


-iili-taiicc-   need   miK'  l)e   iMciitiniied.      We   ^liall  dwell    iiKire  I'nlly  ii|)(iii 
the  iiii|Mirtance  nl'  tlii-  matter  in  eiin-ideriiiir  the  special  eti(ilii;;v. 

When  trrnwii  in  a  iiicilia  contaiiiiiii:  L'lucii>c.  lactusi'.  ni  sacchamsc,  tiiere 
i>  lie  |inMliiclii>ii  ot'  ^Ms.  Wlifii  introduced  into  the  |)eritiiiieal  cavity  ot' 
ii'iiiuiiM/.ril  i:uiiica-|iii:s.  or  wlieii  introduced,  toL'ctlicr  with  scrum  tVom  an 
imniMnc  animal,  into  the  |icritonea!  cavity  of  normal  L'niiiea-|iiL's.  the  liacilli 
i|U'''  IV  lll^^e  their  motility  and  break  up  into  small  Ln-anulc.- — the  >o-calleil 
!''■  ''cr's  phenomciiou  I  {'fcitfer  and  Kolle  '  i.  It'  a  honillon  culture  of  the 
tvphoiil-JKicillus  is  mixed  witli  scrum  from  an  iiiimune  animal  or  from  a  ;)er- 
sou  after  an  attack  of  the  diseti.se,  the  liacilli  heconie  imiiioliile  and  collect 
in'.o  L'roups  or  clumps  i  Durham '■' i.  l-'inally,  if  such  a  culture  is  mixed 
with  serum  from  a  patient  duriiiLT  an  attack  of  the  disease,  a  similar  reac-tioii 
takes  place  i  Widal  '  i. 

The  especial  hehavior  of  cultures  ot'  the  hacilliis  nl'  Elierth  n|ioii  the  solid 
and  liipiid  initrieiit  media  mentioned  has  liei'ii  dcterniiiiiMl  most  imnntely. 
Willi  reference  to  tlic  detail's,  which  would  he  out  of  |)l!iee  in  a  work  of  this 
kind,  the  special  treatises  should  he  consulted.  Siiiie  statements  may  he  made 
here  with  reference  to  the  lieliavior  of  the  bacillus  on  trelatin  and  airar. 

Siah-cultures  in  irelatin  ap|M'ar  as  delicate,  irravish-w  hite,  sli'_ditly  Lrranular 
lilamcnts,  hccomini;  more  attenuated  toward  the  iMittom  ot'  the  test-tnhe. 
I  poll  the  surface  of  the  i^elatiii  the  liacillus  exhiliits  active  frrowth  in  the 
form  of  a  thin,  hlnish-irrav  or  <.'reetiisli-<;rav.  sliLrhtIv  iridescent  deposit, 
|iro(eediiiir  from  the  point  of  puncture  and  soon  reachini;  the  liorder  of  the 
Ldass.  On  closer  inspection  it  will  U-  noted  that  the  outer  Iwirder  is  not 
reirular,  hut  slif.'iitly  serrated.  The  hacillus  forms  n  similar  thin,  iridescent, 
irrayish-nlule  or  hluisli-wliite  deposit  in  <relatiii  plate-oiiltures.  Here  the 
supcrtieial  cultures,  which  exiiihit  no  trace  of  li([uefactioii,  ap|)t\ir  at  tirst  as 
small,  distinct,  yellowish  in-  I'rayish-yellow  irraniiles.  After  a  short  time 
a.-jrcr  circular  spots  apjiear,   similar  in  I'olor  to  the  ile|)osits  in  stali-cidture 

•eiit.      Sioii   the  center 


anil  streak-culture,  trravish  white  and 
of 


ikewise   iridi 


of  such  a  spot  appears  irrayisli  vellow  and  opaipie.  while  toward  the  periphery 
the  culture  ;:radiially  liecomes  thinner  and  mo.'e  translucent.  These  small 
areas  also  have  an  irreL'ular.  serrated  iiiar}rin,  which,  as  niieroseopic  exaiiii- 
nation  shows,  represents  a  delicate  wrinkling  of  the  culture,  extendinjr  from 
center  to  the   |)eripliery. 

Stah-ciiltures  in  airar  also  appear  as  (ielioate,  slitrhtly  irranular,  urayish- 
white  tilament.s.  Here  likewise  the  superticial  growth  ahoiit  the  |Miint  of 
puiieiiire  is  active,  so  that  it  soon  approaches  the  wall  of  the  test-tuhe,  hut 


■  /rifs,-/ir.  /.  Hiiijunf.   lid. 


■  I'viC.  <./  the  Ji'^t/dl  .Vkc,   lid.  lix. 


I 


i 


30 


ryi-i!"iii  rivri! 


the  tiiiirLriii  is  nut  sfrrMliil,  l>iil  rallicr  r^  i<l  mihI  rciMihir.  I'imhi  riLriir-iiliitcs 
ul^n  tlif  lafL'i'.  ii>u:illv  rnmiil  nr  ulilnu;.'  culoiiifs  are  imt  scrrali-d  at  the 
|uri|ilurv  a,-  "ii  Lri'laliii.  Tlify  a|i|itai'  ii|iai|iic  ami  yellDwisli  white  at  llie 
<(iilc-r.  au'l  lunre  traii.-iui't'iii.  uiiili>h.  ami  mil  ii|iale>i-eiit  towaril  the  |)eri)ilnTV. 
.Micni-c(i|iically  tlu'se  cultures  like«i-e  are  nmre  nr  lo.-i  ei)ar>ely  puiK'tale. 
uilli  rriilnruLral  linear  t'iiriiiali''ii>  similar  In  llmse  iipoii  L'elaliii. 

lv-|Hriallv  iiMicxMirlliv  i-  llir  liehavinr  i>t'  llie  ty|ihiiicl-l  aiillus  ii|inn 
|Miia|ii.  as  lir.-t  cai'iluily  >iiiilie(|  liv  (iatl'Uy.  a  i'eatiire  thai,  acenriliii;:  to 
exi-linir  kmiu  Km):.'!-,  is  not  e.\hiliiteil  liy  any  "iher  ]ialhii!.'eiiie  iiiier(i-iir;^aii- 
i-iii.  ir  a  ili>k  111'  hdilr.]  |iii|alii  nl'  fieiijy  ai'iil  reaetimi  is  iiaieulated  with 
a  l\|ihiM.|  ciiltiire.  si'ancly  any  (litlereme  in  the  a|i|iearaiiee  of  its  surface 
will  lie  a|i|irei'ialile  In  the  unlraineil  rye  aller  the  lapse  nt'  i'orty-eiLrht  Imurs, 
as  cnni|iareil  vwlh  ihe  >url'ace  nl'a  sterile  di.^k  iit'|Milalii  similarly  ex|iiiseil  hut 
lint  sn  imieulate'l.  I  )ii  nmre  eni'eliil  sci-utiny,  hew  ever,  the  iiit'eeteil  ]iotalii 
will  appear  Mirmwiial  h>s  >nii"ilh  ami  innre  nmi.-t  t'nr  a  iirealer  (ir  lesser 
ilistance  iVnin  the  pnml  nt'  inciculalinn.  It'  a  jilatinum  limp  he  stnikecl  nver 
llii-   area,  a  seii^e  i.l'  imii-a^eil    re>i-iance  will    he   felt   as  cmnpareil  with  the 

unii ulaleil    piilato,  ami  at  limes  ii  is  pii>.-ilile  tii  ileta<'h   small   lihiMieiits  or 

threails  \uih  the  hmp.  In  a  wnril,  nni' can  cnnviiice  himself  that,  startinjj: 
I'mni  the  puiiit  iif  inorulalinn,  an  extremely  ilelicati',  mnist,  ^'listeninir,  enliir- 
h  s^.  transparent  cdaliiiL''  has  t'lrnuil  upnn  the  piitatn.  <  )m  iniia-n-cnpic  exaiii- 
inatiiin  tiiis  memhrane  will  he  fnuml  tn  consist  of  a  pure  (ailture  of  typhnid- 
hacilli,  which,  iransfeneil  to\arious  nutrient  ineilia,  exliihit  their  charac- 
teri.-lic  ]n'cailiarities,  especiallv  the  spontaneous  movement  in  houilloii  pre- 
viou.~lv  relerred  to.  .'"ie.ce  i(  was  first  ilescriheil  hy  (iatfk\-.  this  scarcely 
visihle  deposit  has  heen  recoi;iiizeil  liy  all  ohservers  tis  an  e.-iiecially  impor- 
tant chtiracteristic.  This  opiinon  is  naturally  not  iufliienced  hy  the  ohserva- 
lion  that  upon  potato  ot'  neutral  or  alkalim'  reaction  or  rendered  artiticiallv 
alkaliia-  the  nienilirane  hecomes  vi;-ihle  as  a  greenish-white  or  yellowish- 
trray  or  even  hluish  coatiiiL'.  which  not  rarely  is  le.ss  exteiisivi'. 

ll'  after  tlie-e  lew  refefciii'es  to  tile  inor|ilioliiii;\-  iiiid  tile  ])liy.-iiil(rjry 
of  the  I'.liertli  hacillus  \M'  pa--  to  a  coii-idei-ition  of  its  n'l/e  in  the 
ilcvelii|iineiit  and  (li— eiiiiliatioli  of  ty]ilini(l  fever,  and  to  a  (le-ei'i|>ti(ill  of 
till'  pro|ierlie-  that  confer  llii-  power  upon  it,  the  (|ne>tioii  ari-e- : 

'  'iiii  li/j/linlil  fcrcr  lir  c.rjx  riiKi'iifn////  iiiilid'id  lit  ii,iiiiiil/,i  hi/  iiidculd'ion 
iij    till'  tiii/li(iiil-/ififilhis .' 

The  e-tal>li-hnicnt  of  tlie  etioloiry  of  typhoid  fever  lias  heiMi  in  no 
-mall  iiiea-iire  re-liained  liv  the  cii'cmn-talice  that  ;i  disease  wlxiUy  eor- 
re-poiidiiiL''  to  tv]>lioid  liver  in  hiiniaii  lieiiiifs  iipjiarently  does  imt  oeeiir 
in  any  -peeie-  of  animal.  It  wa-,  thei'efofc,  iVoiii  the  outset  iin]H'ol)- 
alile  that  till'  di-ea-e  I'ould  lie  developed  experimentally,  and  as  a  matter 
of  t'aet  tlii-  ha-  not  \  ci  lieeii  po— ihle.  <  iatVky,  in  his  well-known  work,' 
was  imalile  <itlier  after  administration  of  pure  cultures  of  the  haeilliis 
liv  the  nioi'di  or  after  intravenous  injection  to  ohtain  d(-eisive  results  ; 
and  also  the   ex]ieriinent-  of   Frankel   and  .'^immonds,■-  however  valuahle 

'  Loe.  cit. 

"^  CenfralhlnH  J.  I.r,),.  M.  /  .  No.  44,  IHX,-, ;  X,,,  :',;i.  IKSC.  /)/,■  „fi„h„/,sch(  Ii,<lni. 
tii,i,i,/,.i  Ti:ph)i^'i'i<-ill'is.  Ilaiiilmrir,  ls,si,.      '/..Hfdir.f.  llu<ii'-ne.  lid.  li. 


JTlni.oi/y 


:n 


lliiir  i(-iill<  ill  citliir  ic>|)c<'t^,  liavc    viclilrd  im  wlmllv  cipiicliisivc  results 
ill  llii-  CMiiiircliiiii. 


lie  iiiVc^liLMtiii's  liiiMH''l  wcri' 


al>lc  liy  iiilruvciiiiu.^  a>  well  as  liv  iMlra|KTi- 
liiiit'iil  iiijrciioii  (it'  larLTi'  Minoiini?  of  [iiirr  ciilliiri's  nf  tv|ili()iil-l)acilli  to  cause 
i;i|iiill\'  lata!  syiii|jlnHis  in  inii'i-.  uilli  [nM'iiliar  aiiatDiiiic  ifsicms  :  ^uclliiiLr, 
( Mil  i^iilaU'd  ulcii'alioii  nf  ilic  I'olliclfs  iit'  tiic  small  ami  tlic  lar;.'i'  inicstiiu-, 
tM_q.ili(T  uitli  rciciit  iiilillraliuii  of  tlic  incsciiliTic  ;:laii(ls.  cloinly  suelliii;.' of 
llic-  liviT  ami  llii'  kiiliifvs,  ami  roiisiilcraliic  ciilarL'oiiii.'iit  of  llic  s|iifi'ii. 
.\Ii(  rosro|iic  cxaiiiiiialioii  disclostMl  also  llic  pn-si'iicf  of  larL'c  iiuiiiIhts  of 
ty|]|ioiil-liiicilli  ill  llic  iKail  hody  and  is|K.'cial  acriinuilalioii  of  tlitiii  in  the 
-|ili-fii.  I'raiiki'l  and  Siiiiiiionds,  liowt'vcr,  alllioiiLrli  tlicv  coiisidcrcil  their 
(■x|H-riiiKnts  of  'jvvAl  sij;iiiiiraiic(' — t'oriiiiiiir  the  fomidalioii  for  siilis('i|iieiit 
f.\|.frim»'iiis  ill  immunity  and  cure — were  cautious  eiioui.di  not  to  idcntifv 
iniM|iletcl"  the  s\-m|iloms  induced  with  Ivphoid  fever.  It  was  soon  found' 
iilxi  that  no  miicNiorihy  iimlli|ilicatioii  of  the  liacilli  introduced  into  the 
animals  toiik  place  in  the  livim:  oriranisni.  In  addition,  it  was  noted  that 
ill" 'ulalioii  of  small  niimliers  of  typhoiddiacilli  did  not — as  in  the  case  of 
oilu-r  actively  |iallioL'ciiic  iiiicro-orLranisms,  as,  for  instance,  anthrax — L'ive 
ri^c  to  noteworthy  symplonis.  Finally,  the  circumstance  that  the  miinials 
^'eiicrally  diccl  hefore  lhi>  end  ot'  the  (irst  day  and  earlier,  but  warcelv  ever 
hiltr  than  after  three  days,  aroused  suspicion  that  the  condition  was  rather 
a  liircit  intoxication  than  a  true  iid'eclioiis  disease  resultiiij,'  from  the  nuilti- 
plicalion  and  continued  development  of  the  bacilli. 

The  certainty  of  the  view  that  the  condition  is  due  to  the  ai  i  'in  of  toxins 
and  not  of  the  bacilli  was  established  by  the  ex|)<'riments'(if  Sirotiiiin,' 
Hrie^'er,  Kitasalo,  ami  Wassermann.'  l?y  boilin<r  tlie  cultures  or  bv  eliiii- 
inatint:  the  bacteria  by  filtration  it  was  po>sible  to  introduce  the  toxins  alone 
into  the  animals,  and  thereby  to  obtain  the  same  results  as  Friiiikel  and 
Siininoiids. 

'i  he  statements  of  more  recent  observers,'  that  by  .systematic  auirnieiitation 
(if  the  virulence  of  the  bacilli  they  can  be  rendere.l  "actively  pathoirenic  for 
animals— that  is,  their  further  development  in  the  Vniuiz  body  with  the  prfv 
duction  of  typical  sympioms  can  be  brou<:ht  about — yet  reipiire  eoiiHrina- 
tion.  In  siicli  an  event  material  advaiita;.'e  would  be  ex  pet  ed  less  for  the 
etiolo^ry  than  for  the  solution  of  certain  thera|«  utic  |)roblems. 

In  none  of  the  previously  quoted  ex|)erii  nits  do  any  of  the  observers 
claim  to  have  prodiicecl  in  animals  a  disea.-e  with  a  course  resembliiiL'  that 
seen  in  human  typhoid.  A  later  observer.  Heiiilinirer.'  found  that  bv  pro- 
lomred  feediii;:  of  rats  and  rabbits  o.i  veiretables  soaked  in  water  containing: 
lyplioid  bacilli  he  was  able  to  induce  a  continued  fever  la.stin<r  from  ten  to 
twelve  day.s,  accompanied  by  diarrhea,  los,s  of  a|i|K'tite.  and  uastiiiL'.  Four 
of  ei^dit   rabbits  experimented   upon   became  sick  ;   one  was   killed   on   the 

'  Sfc  thi'  iirliri.^  ,,(•  li,uiHi-iirn>ri.  Onlralhlalt  i.  Pin.  Mr./.,  IHSti.  Wolfowicz 
i' HMui]i;;;irtcn ),  hi.iNipirul  J)is.^,rfn/ii.,i.  Koniirsberi;,  1HS7,  t^jnitiiiin,  Zri/schr.  f. 
Ilwi.nir.  \M  i.,  IHS.;,  H,.iiriiornti,l  Pripcr,  //m/.,  15,1.  i.  u  ii.  U.  f^trvu.  V.Jkmann  s 
Siinini!.  ktin.    \',,rtr..  Nrni-  F'iIl'i'.  N".  1:!h. 


■'  !,',<•    .-it. 

'  <;ill"Tl   aiul    Oinidc,    C<,iii/if,~   rr,ici„s  lic   Ui    s 

('ll;ll,l,.inrs.,.    Ulul    Widlll.    All,:. ill,,    ,!,■    illl^titltt    I'nstiiir.   KH'J1>,    T. 

ri'lli.  /'././.,  T    vi.  ;  //.„/.,  T.  vlii. 


'  y.eitschr.  f.  Jli/ijinif.   l!il.  mi, 
s   -ii'ti-  i/e   lilohnii,    \m\.    No.    Id. 
No.  1 1.     Smia- 


'  Ann.  il,  'IiiHt.  I'. 


V. 


\i. 


TV  fill  III  I  1  i.vi.n 


I\M   ll'lll     llil\.    :lll(|    ('!H-     clic'il    nil     tliC    l«( 

L'awM  |i(i>ili\r   aL"-'iiiliiiiiliiiii  riiiriinii. 


Iflli   il:iv  nf  fever.      'I'linc  of  ihc   fmir 


>LnU((l     .■-WrllillLr    I'f 


ilfcll.      I\tll| 


LlUip|iMi':-  111!   lln'    lu.i   l.iihl    l:i 
.1    ll 


iiicls.  ami    I'fvci'-    |i:ilc 


iimI    iIk'K 


a    f.w    ulcfl>    ill  llic    liiHir  pari  of  the  Muall    Im.uiI.      'I'viilmi.l    l.an'li 


.111. 


liiii'il  fmiii  ll 


Tl 


ic»i'  vcrv  .-inkiii.Lr  ainl  uiiii|Ur  nhM  rvalinn- 


lavc    mil     \  el    liirll  rdlilirillril 


^^^ 


i:;-  ii|i  iiiivv  Icii'  -| 
I 


iiclal   nllc-l 


iiiii-  a-  t"  till'  (li'Vtlii|iiiiriil  iif  t\  |ih'iiil 


cviT    III    liiiiuaii    liciiii:-,  I 


IMC  dt'  the    lii-I    ami    iiin-l    Mii|i"itaiil    w  i 


11    III 


lliiw  ami  Ia   uliat   rmitc  <lu  llic  i/frrtiini--   a;:riil>   leave   llii'  Imily  uf  lli 


latlclll 


till 


ill 


iir-iiiin    will     naluralK     ari-( 


lU 


til    thf    t'lirtlii 


lirhaviiii'  lit'  till'  liacilli,  in  airurilaiin'  v.  illi  tin-  vai'\  iiii:'  (•■imlfimi-   iimli 


\\iiirli    tl 


ii\  all'  I'S 


ariiatril    anil   ilr|Mi-iti 


<l.      K 


(Iric  I'llllllcil 


niirr  w  hat    ciimlil  KUi-   ami   Ini'   li'iw 


I'ialK'  will  it  lia\i'  In  lie 
Inii'^'  a  liiiir  llii'V  ii'iaiii 
tliril-  \ilalil\  I'l'  all-  ia|ialili'  nl'  liiiilli|iliratiiin  imlr|ii'ml<'lilly  nt  llir 
Jiatirlil. 

BY  WHAT   ROUTE    DO  THE   TYPHOID-BACILLI    LEAVE 
THE  BODY  OF  THE  PATIENT? 


II  -liltr  III    llllliicn 


111-  iii\r-tiu''atiiiii-.  "•'  arc  >Iill  in  tlir  lir-t   ^la[^(M) 


l<iiii\vlcili:-f  with  ropcct  to  tlii>  (iiic-linn 
of  tlir    |ialirlil,    a-    wt'l 


T 


-rrri'iion-  ami  cxrrciion- 


1~     lll~    lilouil 


liavr   naturally   n  ri'ivnl   v-\v 


alt('lltll:ll. 


'i'lic    iiliidii    i-   .-rarcrK'    to    lir    taken    into  eon-iileratioii    as 


a    iiKHJiiiiii  of    int'eetion.      Al.-o  tli 
e\|iinHl    air    a|i|iear    to 


e    -Weal,    tile    i-\peetoratioii,    ami     tilt' 

lie   of  .-liirlii    >ii:'iiiti'"iiirr    a-    carrier-    ot'    tlie 


I'l-iii-  of  iiitcctioii.      Direct  C7.ca|ve  oi'  ilie  liacilli  with  the  -weat  i-  more 
than  (loiilitfiil.      lMilati-<l   re-iilts  lielicveil  to  lie  po-itivc  arc  pmliaMy  to 


lie   con-i(lci'c< 


1  a-  due   to  accidental   containination  of  tlio  skin    from    the 


iitotiiic.      .\ltlioiii:li  tvplioid-liacilli  liavc  liceii  denioii-ti-atcd    in  tl 


ca-cd  Iniiir  in  >onic  ca-<>  o 


t'  |iiiciiiiionia,  and.  accordiiii;ly,  eliniination  of 


hacilll    ill  tlic  ^putilin  ami   the  cxpire<l  air  <Mnn 


it    lie  denied,  llie-e  media 


al-o  prolialilv  act  only  cNccptioiially  as  cai-riei>  of  llie  inlectioii.  llic 
-talcniciit  of  Sicard  '  a-  to  the  aliiio-t  coii-iaiit  pre-ciicc  of  tvplioid- 
liacilli  ill   the  expired  air  of  tyjihoid   patients   i-  mo-i   reiiiarkaMe.  and 


lircs  conliriiiatioii 


l-'ar  more  iin]M)rtant  than  all  of  the  .-oiireo  hitherto  con-idercd  are 
the  fecal  di-chai-i;!'-  and  urine.  ( Jciicrally  the-c  are  proliaMy  tiie  exclu- 
sive media  liv  which  typhoid-hacilli  leave  the  hody.  The  hi-tory  of 
tvplioi<l  fever  teaclie-  that  even  the  older  author-,  naturally  tVoiii  dilL  rent 


-tamlpoint-.  con-iilcrci 


i  the  stool-  as  t 


le  source  anil  origin  o 


f  the  di- 


Afler  the  di-covcry  ot  the  typhoiil-haeilli  tlie-c  vi 


ew-  were  coii- 


■,/;,»/..  is'.i-j.  N...  -1. 


I'l'IDl.OllY 


33 


-idrra 


l,|\   loi-iilicil   l.v  ilic  (Icm.iii-lnitioii  ol'  llic  cnii-tMiicy 


(1  tlic  mIiiim- 


,|    ilic  iiilr|-ii-(iri;:l 


ni-Mi>   111  till'  niriliilhiiN    IN 


li'tlMll'ill   111     till'    lllll-- 


lilli',    in    cnll-cilllc'l 


iiiliiil-  1-  I'onlniiiiiii 


iiv  i.r  \vlii<>li  (ii>|)unuiiity 


tor  ;iiliiii\iinv  \v  iili  mtc 


-l!ll;il 


111.  1 
lion. 


.rl'liM 

If. 


■iv  iiii; 


1  (,f    lAl'nliali'lll    :H1 


tVdiii  tlic  .■;irlii'-l  -lai. 


il  tlic  <U^;a-l■  to 


il    llir  cciiiipjitioil   ol'  tlic   l(f<icc,->    i>r  lllccl-.i- 


111   :hI< 


lilioii    t(p    llic   aliiiiiiliiMcc  u 


f  tlic  liiiciili   ill   till'   I 


if   inlc-tliic    the 


-c;it   ol    1 


if    llic    I.I 


ttcr  anil    the 


ic  -|iccllic   K 
.1 


1--10I1-,  the  re 


itivch 


lofllollS 

duration 


iniinlici-  ami   coihoii^ik-.-   o 


t    tlic  tlailv  Iccal   ( 


arc  taken   into   con 


-iileraln 


llicfc    call    lie    no   < 


«IlMl|-      CO 


ll-Illlltc 


irolitic   -oni'cc 


ilenoioi;ic   exaiinnation   ol    t\  | 


iniluiiitalily    ami     f|-ei|neiilly    the     [ 


li>- 
lollllt    tliat    tlie 
for   the    coiita<;iiliii   of  typlioiil    fc\cr. 

i^ii-tniii  il 
ilioiil-hai'illi.' 


f  t\  iilii M   -looi-  lia-  al^o  (li'in 


ircMiu'c    o 


f    living:    typ 


i; 


■nt    oli-ei-\er- 


li: 


-tal.li.-licd    tlii>    f-et    \Mili   certainty 


ill-tame,  { 'liantenic— c,-  who  in  exaniniation 
|i:iliinl-  fiilcd  to  tind  iIk'  liacilli  only  thrice 
-taiitlv,    in   accordance   wit 


it'  the  >tools  ot 


|i;  tyj) 


Il   the   nature  of  anatomic    Icr 


'I'hcv  arc  found  ino>t  con- 
^    from    tin' 


lic:iiiiiiiii;X  "i 
or  fi'ciin  the  p' 


the   >ceom 


1  week   to  the  end  of  the    t 


hird   week   and    l:it( 


d  of  mednllarv  intiltration  of  the  lyini.liatii'  ^trllctlll•e<, 


their  exfoliation  and   nlci 


■ration,  until  the   ci 


iiiijilcte   eica 


tri/.ation  ot   tin; 


( )n    acc'ciiint   el 


the   (litficultv   atteiiiliiii;   exariiiiiatioii   iif    the   >to<)ls    for 


tv|iliiiiil-liacilli.  a  >\m\\ 


Icaiiil  reliahh' iiicthoil  for  their  isolation  ha.-*  loiij;  In 
littiiailties  are  (le|ieMilcnt  es|ieeially  iiim)Ii  the  coiisfa 


wantinL'.     'I'liat   tl 

ce  ot'  luiiucroiis  other   iihcro-orL'aiiisins  is  ohvious. 
if  these  is  the  ci 


lit 


I'he  most  troiihle 


Ion  Imcillus.  which  reseinhlesthe  ty|ihoid-hacilliis  in  so 


many  res|ie<'I 


The  cfliirls  to   isolate  the  lynhoiil-haci 


iliis  from  the   stools. 


iiiire>licciallv  to   diti'i'rentialc  it   from   the   colon    hacillns,  have   resiiltc.l  in 


tlie  I 


lulilicatio 


n  ot  several  liiiiiilrcil  iiapei^ 


i"()   to   the   time   of  the  introduction    hy  Eisner  '    of    the    inei 


mm    111  w 


ahuosl    insiinnouiitalih^ 


illlllcultler 


known  hy  his  iiaiiie,  the  isolation  of  typlioiii-lpacilli  from  the  stools  presented 

ties.       l?v  the    use   of   this   medium    Klsner.* 

iei>   were   ahle   to  isolate   the   typhoiil-haeilli 

(luriiii:  the  fehrile  sta'.'e  in  u  larL'e  propor- 

r,  the   possihility  of  contai'iiiiaticii 

aiiahli,'    I'iorkowski,"    Heiiiv,'  and 


L'cr,'   liielianlson,    ami 
the  \'vr^'<.  of  typhoid  p; 


oil 


In    1 


icse    cultures,    lioweVf 


iv    uriiii'   \sas   not    L:uarilei 


aiiainst.      (' 


iillicrs.  Iiv  the  use  o 


f  special  media,  have  also  iici 


n  ahlc  to  ilemoiistrate,  with 


,1   Sii 


i.l-.    ill    til.  J-  r;illi.  -I     |illl.lic-Mtinli-.        V\\W\VT.    I)iUts,-hl-  >,>r 


IssT.  N...  -J-.'.     Cliiir 
I'tiilt  f.    /lii/,/i-,-:.J,.,,i 

No.  ;!. 


MitU.I    :ui 

.1  w  i.iui.  a 


1(1  (iMl.l-chiiii.h.  <:nlr<ilM<ill    t. 


kr,„.  .1/../., 


/,.•'"/,.   IssT,  N, 


Kiirlin-ki.  ('•uli-nl- 


;/,,./,,-»./-■,    IM.  vii.      Vilrh.mr.    /,«h.-.7.     ISSi;,    v 


'I.    li. 


.1.-  Iii..l..  Mr.tin-  fell,  -J-J.  isai; 


/.,',t.   i    llua..  liil.  wi..  l^^'i 
■  lh„ts,-h.  /,.-./.    (I'..<-/,..  IS!,,-,. 


/<„../..,<    Mr, I. 


/.rit.  ; 


lh,n..  H.l.  \s 


'Il}\.    vcl.    I'WXV  1 


nl...  T. 


i..  N...  IS. 


I'.,rlrn.  /.I',:.    llo.A,,   lK>U.  N. 


'i 


34 


iiiiirc  i>r    li  .->  I 


11-. ,  I 


ivriiiiiii  I  i:\'i  I: 

li,.    !,a.i!!u-   "f  H|.li..i.l    in    ;i    l:n-.'r    |'i'n|,. 


nitill     nf 


I  -M.U  111-'  "Hi,  :i  n.u  nirllm,!  h:,,-  ,-..h,l,..l  tl,r  Iv  pliniil-lunllu.  ti-ti,  I  u' 
r,.,-,-',,,  IT  ,:,-,-  nul  uf  ■.'!  .lU.llr.l.  TIh^  ,..M1,1V:|  nlllv  niR-lN  l.rtnn  llir 
1,M  .l:u   ..r  111.-  >''"n.l  uirk.  Mii.l  .lwi|.|.r:nv.l  nmiIi  iIh'  t;ill  c,t    ll.r  liM  i . 

|),„-iii.'  ll)r|i:,-;   l.-u   \(;ii-  v;.i-inu>  nl,Mr\vi>  l,ii\.Ml,inon>lnil..l  llM-jniM 

fn vw■^     uill,  ulmh    |^|.|H.|.I-I.;,^|||,    unur    M,    llu-     nnnr,  mnl    l.aM-    ..ilK-.l 

;,„..nll.nl..ll„-nn|.o,l:n,l  ,../.  ,,|  tin-  -rrn  m.„m„  i1„.  -|.rr:„l  „I  llir  .1,-,  a-.. 
In  l^'.iit.  NiMiiiiaiin  .Kinnn-iral.'l  lv|.linl.|-I.Mrill,  lu  I  lir  nnn.-  nl  II  ..uImI 
-IS  ra,M>  .AaihM,..!.  Hi-  n-iill-u.iv  , .  .,  im  .1  u  il  1,  ^..iia  .Ur|.lir,M„.  Uv, - 
,.,,.,  ;„„1  ivrnvr.l  „n,n„ti,i;,a.in„unlil  IM-uhIiL^.  in  I  >:•>.  l.ul.h-lir.ll  i. 
n-ui|,  of  .■uhiin.-  ina.li-  Uniu  llir  uniir  in  -.'l  ra,-,>.  VMll,  i-nlaimi,  n|  I,. 
tvnl.nMi-    rn.iii  :;.       i.alrr.   l;irl,ar.l...i,  '  ,,l,ian».i    ll.rl.anlh    tr-iii    L'..  pul  ..t 

l(il,a,-r,-.xan,iih.i      l'^.  1   |..i-.vul.  ;  ami  ll-r -Sniilli    ol.lani.Ml  ll..n,  In.n. 

11    .,|'   :',')  .a-r-      _'S    |„.r  .Till,      llir   uiiiic   n.iiIaiiiiiiL'   :il    liim-  a-   iiiaiiv     a- 

.■,(ll)(»i»il.(lll -aiii.-ni-    ill  .a.-li    nil.ir    .viilinu  li  r.       I»nriii-    tlir    pa-l    .\rai-. 

l;illil  1:m(1.  iVoiu  the  uni).'  nf  ;,..  I\|.i,..i.l  l.\i  r  |iali,  nl:-  iii  ll"'  -l-lin^  H;'!'" 
kiii-  lln-i.ilal  Ihr  tv|.lM.i.M  a.  llli  urn-  iH.lalr.l  in  I'.i  rax  -.  W  lnl-  lli-  l^i;  1 
,,r  il„-  l,v.|ii.ii.-.  ni-  ll,r  l.a.illi  in  ll.r  uiinr  1,-  al  UiiM-  nt  Miiporlan..  n, 
.lia-nn-i-.  il-    -u:^u■-^    iin|...rlaiHv    ,-    innlalmn    to  llir  :■  ival    ,lan-.T  nl    ilir 

MMva.l    anil    tran^H.i-M f  thr  iliM-a-r.       Il    -l-^u-  llm    -Miv  n,-    ran     ulii.  I, 

^hnul.l  I..'  nliscrvr.l  il,  M.Tili/alii.ii  nfllir  urinr.  In  i:uanl  a-aiiiM  aiiv  clian.r 
i-niiiainiiialinn  nf  ilit-  walrr-suiipl)   "V  IixhI. 


\ 


THE  VITALITY  OF  THE  TYPHOID-BACILLI. 

W'hal  aiv  ilin  .•.indilioii-  nrn.—arv  tin'  |.r(-nr\ini;  tli<'  vilaiily  of  llir 
tvi.li.ii.l-l.a.-illu-  williiii  and  (Hit-idc  llm  lininan  Ii.hIv,  and  xvliat  ivla!i..n- 
s'liii.  .In  iIh-c  nondilicMi-  K.'a r  In  inti el imi  nf  tli,  in.lividnal  an. I  In  lli,' 
p.n.Tal  .li".aninalinn  nf  tiu'  .li-.a-.' V  Aiv  ill.-.'  .■nn.lilinn-.  an.!  tli.' 
ivlali..!!  nf  llin  tvi,hni,l-l,a.aliii-  t..  tlu'in.  -nni.-i.Milly  u.ll  nn.l.r-lnn.l 
ti.at  an  .A|.lanalinii  nf  ili.'  iv.'..uni/.<l  iiL'tli-l-  nf  nri-in  an. I  -|.r.'a.l  ..f 
tvpli..!.!  f.'V.T  i-  i>.."il.l.'-.'  Nninnr..us  inv,-tiirali..n-  in  r.-ar.l  t..  ih.' 
vilaiitv  nf  til.'  lv|.l.ni.l-l,a.illn-  nn.l.r  varinii-  .■.m.litinn-  liav.'  yi,'l.i..l 
important  iv-nli-.  In  i^.'n.Tui,  lli.'  m-nli-  ..f  tl,.-.'  inv.-ti-aii.in-  hav 
ma.l.'  M  |>..-iliv.'  im-w.r  tn  tli.-  latt.T  .|U.-li.-n  pn-ild.'.  Kv.ii  tli.- 
alw.n.v  ..f  -|.niv  fnnnalion,  wiil.-l.  i-  >o  inii.ortani  with  ivlati..n  to  the 
ivM-lan.v  ..f  l.a.t.Tia.  i-  not  >nlli.'ic!it  t..  llirow  .loiil.l  ..n  th,'  iialh..j;.'nir 
r-i-iiilinan.-.'  .if  t!i.'  t\  iilmi.l-hacilln-. 

A  'laP.M'  vri.-  .if  ..l.-.Tvatinii-  atV.ml  ini|M,rtanl  cvi.l.'ii.'i'  in  fiv.,!'  ..f 
til.'  |MT-iM.iiiv  .if  tlw  li:i.illi  in  'III-  livin-  hnniaii  li.i.ly.  Th.'  tyiilmi.l- 
l>a.'illii^  lia-  l..'.'n  f-.nn.l  in  intlaininamrv  .xn.lat.-.  aii.l  in  |.<Ti.iMitii'  an<l 
iniK.-illar  .■..ll.'.'tinii-  ..f  pn-  .'an-.'.!  Ia  typh.ii.i-lia.-iili,  aiiv.'  an.l  .'a|.alil.' 
of  ninlli|.li.'atinn  a-  l.m-'  a~  a  varan.!  .'V.'ii  ]..n.j','r  aft. 'r  an  att;i.'k  nf 
til.'  .ii^-a-.'  (Salili.  Hint/).       It    i-  tin.'    that    .'V.'ii    >h.iiil.l    th.'  ha.'illi    hn 

.    1/,,/     Y,,-'.'    v.il    IxNNiii..   N"     1'.'.  '  /•'"■'"'    '■'"'■    ••■•"■''"   1^'"'.^    1-1 

■'  VcntralM.  /.  link.,  l^;.^,  N"    1  l-  '  •'""■    '•■'V" '•  ^'"'^  ^..1.  iii.;  M-..  v„l    iv. 

i   I.inart.    I'.Kin.    \.il     i.. 


i:  III  It  ')<:)'. 


•tV  .'I-  a  i-c-ult  "f  -|H.iit:inc(iii-  rii|itiii-r  Mf 


li'  imi-iiiii  111'  -Hell  I'liri, 


,||,,i,|     illllvlinll    will     ll'il,    :l-  :l    nilr.    lie    clll-i'il     I  111  Tl  1 1\  .         NrNCI'lln 


III   lin-  i':i- 


i|     (ili-rlll'i-  rllol.i^r\    -iii-li   a    IKi 


~-il<ilil\    ~ll<>ll|il    mil    III'  III!   nut 


,r  i-,.n-lilir:it 


rlir  ri-i-lailrr   of  lllr  ll.nilli  a|i|"    lI'-    111  111'    ralln  !•  lilllitnl    ill  lllr  lllllliall 
il  I  Ml-.       Mllinll-ll   Illulli|iliiMliii|l   ll  I-  llri'll  ii!i-i  l\iil   1"  I  iIm'  I'l.lii-   -Iml-llv 


all'  r  ill  :i 
tiirtimi    - 


alw  i\  - 


ih  I  I-  iMPl.rl  ami    >iiiiiiiiiiiil-,     111 


111  !■  -1.   Illi 


■iirrniri'  nl    iiiiln 


HI    r\i  ll-   an     ni|iiniiii-     iiitliii mi 


'l"li:il    llii-    aclimi   lamiiit 


ill  prlliji  i|     IIIMill,      II 


ImwcMi-,    ami    llial    tV iln'    iiruiiliv  larlir 


It     III'    \  il w     1  all  llll     riill-liirralliill     lllll-l 


ihii-i 


Ihii-i'    iliail 


if   w  iiliiiiil    li'Vi  I-.  a|i| 


n:ir     ilrllli'll 


II'     Mivill     III     till'     hiiillr-     111 

-li'aliij    li\    till'  iili-i|-\aliiiii- 


if   Kai'liii-ki    ami  111'   I'lli-i,  ill-'    fiiini'i- 


if    w  Imlil    li 


mill    liv'iiiii'  liarilli  III 


lllllliall    raila\ia'-    a 


flir    lliivi-  iiiniilli-,   \\liilr    llll'    lalliT    fmnul  tln'iii    in    a 


i\  111^  -lair  in  llll 

'II.      lirr-i-Ii'lli 


li.iilii-  111'   ilrail 


iiiiinal-  a-   lair  a- 


llir  -r\  rlllirntll  il:i 


if   tl 


li    alliT    llii'\    li:lM 


ll    till'    litiiiian    liiiih    1- 


lli\    iif   fiirlliiT  iii\'r-rn;arniii  III  \al' -  iliMi'l -.  pliv-iral  a-  \\f\ 


Willi  ri'^anl    in  llir  inlliirm-r  <>\'  varinii-  :i'iii|i 


I'aliiri'-.  II  ha-   ali'i'aily 
tlirr    i-    lllii-l     fivnr- 


Ihi'Ii    iiiililii.lii'il    llial    llir    |ili\ -inliimr    \«i'\\     liiilln  /  iln 

aliji'    111   uiiiwlli   anil    ili'\  ili.|iiiirnl  :    Iml    ^il-n     nnHliTalr   cMrnial     Inii- 

|„l,l|ll|'i-     a|i|irar     In    rVll'l      lln     illjlivioll-     illtl  I H  lli'l'.        'I'ln'     IVjillniii-liai'illi 

-iijrl'aiilr    lli'HTri'-    cif     I'ulil.         I  llrV 
in    ('.(II      1".  I,  ami  i'\  I'll    rciiralcil 


ll'r     I'Stl'i'lllrK      n-l-lalll      111     I'M'H     run 


i--i-l  al    lrni|H'raliii't'-  a-  \n\\  a- 


tni'/iirj'   an 


I   lliawiiiir  "t    ll 


nil!   I'liiilaininL;'   iln'   iiaiilli  iln   iml    a|i|>('ar   In 


-lni\     llii'in     I 


(  'lianlmir— 1'     am 
llii. 


Wiilal,      .lamiw-kv  ').        Tl 


Mil  llir  illii-lr.iln 111  Ml  llil^  rill linn  I-  l;i\i'11  Iiv 


I'l-ncliii 


11'     nm-t 
ilp-(  r\('(l 
('.  (.".o.:!" 


llial  i\  |iliiii(l-liai'iHi  k('|it  ill  ii'i' at  a  lrin|)i'ranin'  lictwrrn        1     < '.  I 

j'.iaml       11     ('.(!■_'. -     I'".)  rrlaiiii'il  tlii'ir  \italil\  fni- llirii' I tli-.    Tlii' 

lia.'iHi  arc  fii-  iiinrc  -m-ilivi'  In  |ii;^li  ti'ni]M'raliiiT-.  cnlliin-  il\  in^''  in 
fi'niii  llll  In  lil'tci'ii  ininnlr- lit  a  t<'ni|ii'ratnri' iif  lin  I!.  (i'i~  K.>.  llciit 
i-   -ii|i|il(iiiriin'il    liy    li^rlil    in    tlic  (ii'^lrnrti if   iIh'   liarilli.    wliiili.   a- 


iiiiliiii-r  '  \\a-  llll'  lir-t    li 


I  -hnw,  a 


ml  llii'ii  •): 


iiinw  -k\'  "  am 


I  (iaillar.!,"  ilii 


ilii'ii't  -nnliiihl  in  llir  rnnr-riit'  a  few  lionr-,  while  -iniipli'  diU'ii-c  iia\- 


h-lil  a|i|iiar-  In  nilliiinci 


tlii'in  far  li'ss  imt'ax'iiraMv 


Till'  1 


11'  barilli  a 


llll  ai'i'  rnmiiarativi'lN-  ri'-i-taiit  In  ilrvnn; 


Mixi'ii  willi  iiidi 


liii'iil    -uli-laiici's  nr  ilricil   ii])nii    inaniinalr  ii''ii 


rt iltrn-ils.  inati 


/,."•.  ell. 


Arr/,h-    i.   /■;,, 


/',/'/,.    ■/.     VInirn, •,!...     [ill.     \i.\.,    .-;.    4-JO. 


r,,iiralhf,iti  f.  linktri-fh.n"-  >i 


l;,,;,<,/,„/.:,,„l,'.    IM     ^iii. 


M,.l;,„l    Il.::.,:l.    vl,    Nwi.,    1:^S: 

r,  i,i,-,ilhliitt  f.  Itiil.l,  i-,,,l,.,-,i, 

I,..,-    ,;t.  •     1),-  r.i.thi.,,,;-  ,1,    h,  h, 


l:,r.,-<,t.„k.,ul..    li.l.    \i.,    N. 


■  /*  ,s   iilicrij~i'ril'lltts!Hr:<,    K\oll,    1  ^?S8. 


mmmmj^m^^ 


■Mi 


I )  riii'ih  1 1  VI  i: 


(■li'.'--llir\     ri  lain 


in    liii-l     ainl    I 


II 


i  \ 


llirli-  \il:ihl\  li'i-  iiiaiix  niMiilli- 
-aml.  a-  well  a-  in  carlli.  lli.-  I.aiilli  j"  r-i-l  t^T  -i\,ial  Ur.L-  (I  II.  I- 
,ii;iini  '].  Tlic  -ainc  lia-  l»cn  ilmiMii-l  ralcl  li\  \aiiMii-  ,,l,-,i\ .  i  -  t..r  llic 
^(.il.  in  winrli  ih,  lia.illi  lia\.-  I",  n  r..nn(|  |..  Plain  llnir  \i!alil\  fur  a- 
Icn-     a-     lisi'    ami    a    liall'    inMnlii-.       It    i-,    li.iu,\cr.    1..     lir    .  iii|ilia-i/i  il 

(■X|in  — Iv  tlial    II..  .-..nili.  ti  nt  oil-,  i\(  r  lia-    ii..liii.l    innllipli.  ali fllu' 

i  ■•.■:;';  in  lli.'-..il.a  ra.I  llial  i-.liiv.llv  ..|i|i..-..l  lo  ill.' -ratiiil.m-a-nini.- 

ti f    til,'   a.lli.ivnl-     .'I'    til.-     -i-.,i:n,l-uat,|-     tli,..r\      that     inatniati 

(1,\,!, .11111,  lit,  an.!  iv|ii-...in.'ti..ii  ..f  tli,'  t\|ili..i.l  \  irn-  take  |ii:i.T  in  tin- 
>n\\,  ami  lli.i-,l'..|-,'  ..II.'  wlii.li  icikIi  r-  iint.ii  ilii,'  an  i— cnlial  Icaliirf  i.l 
tlii^  doctiin.'. 

,\ ^   ill,.  .Ii-yihir  ,'\|i,'i-iiiii'iii.-.   ili.'Sf   "f   S.'ii/,-    rHi'liiiMiiii.'  (iatiky,* 

ail. I  ScliilliT  '  Ml-,- .'-|H<'iall\  in-lru,-li\.'.  Wliil,  tlu'  la,-l-iiaiii,'.l  tv\..  ..I.mI'vi'.I 
till-  l.a.'illi  ici  nlani  lliiir  \  ilalilN  f..r  M'Viral  iii.iii'li>.  aii.l  ,'vcii  li.f  a  \  .ar, 
on  llirca.l-  ,if  ^ilU.  tt.-..  iin.lcr  -uilalil'- c.ii.liti.ai:^.  llif  I..iiiht  ..1.mt\.'.I  the 
bacilli  In  |ifrsi>;  tV..iii  lu..  t..  tlir..'  iik.iiIIi.-  drif.l  .liri.'tly  ii|>..ii  .l.illi. 

(  )t'  ,l,'i'i-i\.'  inii".rtan.f  i-  tlic  ,|ii,-ti..ti  willi  nranl  t..  lli.    |.,'r-i-trn,'(' 

(.r    tv|ili.'i(l-liaiilli    ill    wati'f.    tli,>    an-u,i-    t..    ulii.li    i~ |.li.al,'.l   anil 

dilli.nll.      Tlir  -iin|.l.'-t    |ir..l.l.'in,  W i  wlii.li  iiiaiiy    iii\  i-tiL;at..i'-  -taftcil 

,.nt,  i-  til.'  I.i'liavi.if  in  .li-tilliil  wat,  r  of  in  ■  I.tili/.d  >|iriiit.r-\\ali  r,  wrll- 
wat.T,  ..r  riv.T-ualrf.  I  'mlif  tlir-«'  ,'..n<litii.ii-.  in  tlic  al.-rii,'i'  ..I  cMrfiii,- 
(.1'  ti'ini>.ratiir,'  ami  of  otiicf  cMraiifoii-  tli>Iiirl.iim  iiillmii.'i-.  it  lia-  Imcii 
(IrtiTiiiiii.'il  that  ill.'  I.arilii  may  pcf-i-t  tor  as  Ioiil'  a-  tliiv,'  iii..nlli>.  Tlir 
iiiLTi'-tiiii:  ,'ir.'niii-tam'i'  lia- ili-v.lopcil — a-  it  lia.l  |.ivvi,iii-ly  Imtii  i-tal)- 
li~lii',l  aK,.  li.f  olIiiT  iiiii-fi.-orj;aiiiMii^ — that  a  ilitVinncf  in  the  vitality 
,,|'  t|„.  |,;i,'illi  i-  .'xliiliiliil  a-  till'  water  in  iiiic-tioii  i-  at  n-t  or  in 
niov.'imiit.  In  the  latter  event  the  l.aeilli  are  more  i,iii.'kly  ile-lr,.ye,l.'' 
Th,'  eomiiti..n-  aiv  far  .iitl'.reiil  in  un-terili/eil  <lriiikin._'--\vater,  river- 
water,  or  hou-eli.,l<i-water.  anil  theref.re  waler  iimler  i.nlinary  <-,.mlilioii-. 
Ill  thi>  eonneetioii  it  may  he  stated  at  the  oiit-.t  that  the  [...-ihilitv  ,.f 
|,r,"-ervii;-  the  haeilli  varies  widely  in  aeeordanee  with  the  ditl'ereiit 
eheiiiie  aii.l  lii.,l..L:i.'  iieeiiliaritie^  "f  the  ri-|.eetive  waters.  l''rom  lliis 
|ioiiit  of  view  it  i-  I'.in.vivaMe,  and  it  lia>  ri'ii.atedly  l.eeii  ileiuoii-traled 
prai'tieallv.  that  in  -..me  water-  the  vitality  of  the  l.aeteria  i- cM-eedinfily 

-li-ht,  while   ill   others   it    may  Ix ii-iderahle.      Of  far  ;.n,-,'ater   imiior- 

taiiee  than    phv-ieal   and   eheini.-  e..iidili.,ii-    in    tlii>   eoiinerti..ii   are   the 
jirescnec  aii.l  a.'tivity  of  water-liaeteria.       N,veithele>-,  the  l.aeteria  iiavt- 

1    (■.■ntnilhlalt   i.    H.,IJ,'r','.h.„u-  ,1.    I'„rns\t,i,l.,n„l..    IM.    XV. 

;  i,.,r,  ,:,_  •  /,...-.  -'.'.  *  /-'"-■  ■•'■' 

S   .|, ./„.,/,„    „„v  ./,„,    l;.-i,-),..li,^', „•//,', /y,n„l.     I!,l.    V. 

"  Ui    .Miittli.il    ..1.    Sta-i'iltii.   .I/,/"'/'"''"     l„^i./„tu.r  r.iirnr   .y>rr!„ir,ifal,-  ,/i    U.,,,,,. 
lis;  I. 


E^}^:-i^^^^^^^^hl]!^!mJ^  .   :-^^ 


i:jI"I.<'i,  ) 


II    loMlliI     |i>     I'l  IMIII 


lliiic  \ll.ilit\'  t''i- 


nil  .III-      1 


:l-    Itin;^    ;i-  i  i^lllv   cl:i\  -    III   l.v   iici 


leal    (liiiikiii;.'-ual(|-    (<   liMiiliiii   --<■    ;in(i     W  uiai,      Sii:iii->    ai 


|)iil> 


iii\  -). 


!• 


Sell      III     ;:rijllv     ciiii 


III-I.IIICI'       till' 

;HmI    l;i"U/    til' 


I'aiikr    III     lliiiin,    " 


laiiiiiiali  il    tlouiii:.'    walir,    a-,    I'nr 
liiili    \\a-    cxainiiiiil     I>n     W  nit  Ini'rfl 


ic   liarilli    WvW   tiill 


III!  tn  ntaiii  llirir  \ilalil\   and  -till  l<>  li 


ijialili'  III'  iiiiilli|il|i'alii>ii  at 


iii^'li  triii|Mraliir'(  -  (  I '»     <  '.  ami 


Imi\  I'  ). 


Ill 


prill-  V*  1  I'c 
ill    I  i\  I  i-iiiii 


ci|)-cr\icl    til  ritaii 
I   ami    ill    till     -III 


I  their  \  ilalily  li>r  a-    l 

iiiii'iil    rnmi    well-. 
1 


II''   a-  llilTc  wiv 


lliat    ilir   iiiiiililinii-.   arc    limn-    I'axnrali!  ■    in    tin-    ciiiiiiri'tinii    in    tin 


ill\    \M'll-iiriit<'it( 


il   i^cnrra!    ami    liuii-c   n 
I 


iiinl'iiil'ii  il  ami  c-iMMiallv  tn  lie  iiiptnl  111  iinc-IiL.'-aliiin-    iiiln  the  iiiixic  i 


li--iiiiiiialiiin  111    till'  iii-ra-«' 


w. 


i-i'  r\|irnniinlal  i'\  iiirin  r  in  tin-  I'lm 
II I  n  1  Miiiilnl  al-ip  III  artitirially  |(r 
lali  I-,  \\liiili  ill  tiinr-  nt'  ('iiidcinii'  I 
iiiiialiK'   iniiiicii'ii 


'  ill<ll 

•1,1. '.1 

tu 

( 

liaiiti 

I'lll 

llirlii 

111. 

Tl 

IC 

iii\  c 

-li 

(•|iar<' 

il    an 

.1 

c-i 

|>ccia 

ll.v 

iiiav  1 

.lav  : 

III 

ini 

iMirl; 

mil 

i-  iVmil    tile    cilll-ct 

lll>  till 


lo-c  Inp  |irc- 
iLTatinn-  lia\c 
.•    cailiiiiialcil 

I  r.;/, 


t'  a-  prc- 


lariui    ha\"c 


lArll     I'll'     Wci 


1-  -iil)-iilnlcs  I'.ir  iiidinary  drinkiiiii-walcr.  'iyplidid- 
lircii  ruiiiid  III  retain  tlicir  vitality  in  tiiciii  t'nr  day,-^  iiiiil 
l<-.'      Other  ordiiiarv  tliiid-,  aii<l   e-|)(cially   hniiillciii,  liavc 


iil\    Ihcii  nieiilinned  as  ^c«id    |irc-er\iiij^   and    nnlrieiit    ine<lia  t'nr   iIil' 
Hi.      Niil    Ic—   ini|M)rlaiit    in    ihi-  ciiiiiiectiuii  al-n  i-  inili<,  and  to  tlii^ 


I'lailcd  rclerelicc  \vi 


II  lie  made  later.       In  tlii-  iilaic  it 


mav  lie  III 


eiitioiicd 


that  the   liMiiili   retain   ilieir  vitality  in   Imilcd    milk  liir  as   Imig  as  three 
liiiiiitli-    and    inure 

I'iiiallv,  a  word   iiiav  lie  saiil  with   rei^inl   to  tlic   |MT-i-lcnc('  of  the 

v|iliiiiil-liacilli  in  the  iiitc-tinal  di-iiiai-ires.     This  is  in  irencrai  and  under 

<     liiiar\     eiiiidiliuns    nut    inconsidi'ralile.       With    a    inmlerate    external 

tcm|ieraliirc  and  a  Icelily  alkaline    reaction   of  the  -tools  the  Kaeilli  have 

jici-i-icd  I'ur  more  than   three   months  ( I\arliii>ki  ').  while  they  die  more 


rapiillv  w 


hen  the  external  tcmperal 


lire  IS  low, 


as  well  as  when  tlu'  stiMil.s 


are  111'  liiLrhlv  ai-iil  reaction,  or  in  the  ])rescnce  of  animoniaeal  dccoiii|«isi- 
tiiiii,  -iieli  a- occms  e-|)eciallv  when  the  ^tool>  are  mixed  with  nriiie.  In 
the  dried   -tools   the   iiacilli    retain    their  vitahty  for  a  f;ir  Ioniser  ]H'rii«l 


than  under   tin iiditiniis    iii-t  naiiicd 


and   tills   nalnrally  i^  of  e-|K'cial 
Miilancc   with    rcL^ard   to  the   dis-emination   of  the   disease. 
All   of   the   individual    >tateiiients   hitherto   made    indicate    that    the 


ly|ihoiil-l)ai'ilhi-,  in  spiti 


)f  the  ahscnce  of  s])ore-formatioii  and  in  spite  of 


a  certain  >cii,-itivene^s  to  individual  intliicnecs  (high  degrees  of  tem|H'ra- 


'  (l,r:,tt,'  l,,l„!.  ,1,-  ,n;,h;n„-  ,i  ,-l,;,;iv,p.:    ISST,   N,,.   !». 


Arehir,^  ,lr  ,„;,l,; 


<,1(,l,\    IM 


'.I;-/,,;/,. 


-/-,„  /.„,.-,-li,sii,„l/„'ifs,n,it.   !!il,  v..  IHHt;. 


h-ti'lt.T,  Ar'„:t,- 


,/,■„,  i;,'iclis-<i 


itlliAiMimt.  IM.  vi.,  ISST 


,')''.  rii. 


■^mm'^'-!^' 


--'i^J^BT'^v- 


1  '"<'■■' 


^ 


38 


V  1  iii"ii'  I  I  \  I  i: 


,|','|/,l'„  ul'.'.IK  -„ll,r,-',..,.m-lilu.r.l„  l..-i-.f  ll,.|..ln,.,ul,lh.l..,i.- 
r,,,:,,.  1,..,.,  ,..(,„,.  ,v....ni/r.l.  rn.l.r  llir  n,n-.  vari-l  ..nliMMrv  ,„„- 
,,,,,,,,,.,,,,,,  i,,|,,,.,,,l  ,,,,,. .nn,M,,,,IK  I  -iH.  l.a.  nin-  ■-  ,;M-1.I.    '••■  ----;: 

,;,,  ,1,,,    u,.K-    :hh ml,-,  au.l.srn  I.T    vtl.m  M>..r,  :,u.l  ui.l.r 

,-,s„r,l,l,.   ,,.n.l,M..n-    .^<n    1  l,n.n,l„.ul    tl,.«n.trr.       A.    :.l.lit ,.  .n.l    r..,- 

,ln-i -    ,Mr,Mi-il,l.       n:„n,lv.    .ha al..,,.'    (In-    |,.a -i-l,  n,  .■   ,,|    ,1,,. 

,,„.      |,„,      aU..     Ilnir    .h-.anlna.,.m     llmm^h     tl,..     ...Mlia     MaM,..|,     l- 

,.,.,,„,',      ir  ,n   ii.i-  ' i-'i""  '!"•  '"i""i  >'"''i^'   '"   ^'"'■'■''   1'"" 

.iMHina,,.,    -Ih.   .Irv    n„,lia    a,v    „.„    >..   1-    1.1 ,    ..l    ,  ou-i.l.ra. U 

...,„„..,   1,., I,  >n.,r.l.al    ,l„....Mta;:ir.,„    aUa,!.,!    ...    ,.an  i,!,-  .,i    ,1,,-t   .nav 

,.,|   ,|,._'iv.-.       \\r  -hall    lat.r 


1„.   ,li-.inhiai..l   il,n.ii.Ji   iIm'    air   l-   a    In.nt. 

|„v,.    ;,u    n|,|,.„innnv    to    nunn    f.   tli.'    v   «">h '   ^""1    l-^' tirallv 

iiiil„.ilanl    irrili,.,!-   >.['  di-,  ininatioii. 


M 


t,-^ 

i-?!-: 


HOW  DO  THE  TYPHOID-BAQLLI  GAIN  ACCESS  TO  THE 
BODIES  OF  THE  INDIVIDUALS  INFECTED? 

\|,n..-t  all  ,,l,v-i,lan-a.va...v,.l  at  llir  fn-rnt  day  ll.al  ll,r  ,li.j,-tivc 
,,.„,  ,.  i,  :,|,|„a,"-.-|-iallv...tnn,i-lMlM.  ^,.^la,i^,n.al-ni-i,Mu,■nl.y 
,a,■.l„■    M,v,,,a.n..,.s.u    .1,.     aln,.,-t  .a.Im-is  .,  l^T-al  nt    ,  n.rv    l.„M. 

•ll„.,„nvi.u..ni-l.Ua,  ,1.,.  ,.v-,  i,t  -lay  .hat  ,^  pJM.i.l  I,  v.  r  ,-  ,..,  iian- 
^i^il,],.  in  .h.  -....■  ,.r  .h.'  ••  .rnr  ...n.a.iuu- -  .li-,  a-,-,  a.  lor  n,-,a„.... 
„,,,„„  ,;.v.r.^.-a.V.l..s.a,an,l  „„  a-l,-.  M,  n-  |„v-,  ,„■.■  .n  .h.'  vi.am.y 
,:,.  ,1,       „i,.,„   i,    „„v,r   .ulli.l,.,,,  ti,r   i^h.■.i..^,a-^^i.li.l-    la...T.       1  I- 

1,,,,..-   an,l    .h.   -Kin.   .h,. l.-l-M,-   ,...-.al-   of  .n.ry   li..'   .h-   a.  u... 

,.x;,n,h,n,a.a.  a,v   -ran-.K    ...   !.■■    lak.n    in...  .■-...-lI  r."   ::  ..  m.  .  >  ■■  ^^ 

.1,1,  n|.h..i.lhv,.r.  l,:in-|,i.....r.hi-ta..t.ini;...i....  .l..-..n.lMnhala.,..n 
.,.„„:,,„-,hl,.  in.-a,v,-a-,-.  i.   uiUh.f' 1    "! .h..iv  .a.v.nl  nn,-.,- 

,,^,,i,,,,,|,,M,,r.al-...l,.M"'i-'-l'^'-^^'i''''''''''-^'''"'' ''''■' ■''^'' '''':'':'■''"' 
;,,,,        In.l.r    -u.h    ,inn,n-,an.r-    ih.    infr.ti....     i-   .•...'^ '  .v'l    >l"-n.J, 

,i,„.K    .li.i,!,,l    llni.i    ...n.ainin,  l.a.-.rrla    o,'    i„H..i....-    |.a.'i'h-   "I    'l-'^'j 

vvl.i.l,    :,l,h..n..h.h,.    hav,.   .ain,  .1  ..m-a.Mv  in-,  .h..  , ,.h  «  ulMn-|.,.v.l 

.,1,,  ,,„  ,1„.„    -uall..u..l   an.l    liav.'   .1m,-   rn,n,„.n...l  th-n'   a.-.,..i.    m    the 

i,iii-iin.'. 

■|'|,c    i.i'in.il.al    Ilia,,, III-  in  wlii'-h   th.'    |...i-..ii 


;,ii,-  iii.raii.'i'   iiit"   tlie 
,„„,,.,„;,    :,,  :.,„n,.a,v,lu„l>uhi.-h   all    ,„h.-,-   a.v   -■arnly  t,.   l.y  .ak..,, 

i.,„;..„n-i,l,nm..n.  -i-.-    i„    -wall...!,,.    ,h,.   inti  ..iv .  a.,-,,.,  .a.h.r  „, 

,.„„-..,,„.■ .■a.Ti.|,nral,-,"-i>i .a,n,na.i..n  ,..  .hr  l.u,va    ravHy  and 

h.  .„.,■,  .un.lin..  -.,■„,. n,v-.,.,-.h, ..d,  ,1,..  nm-.h-.i....  ..f  h-1  =mu1  d.-mk 

,„„„i„i„.    ,|„,    „,,l,„id-l,arill„-.      K.-..M,    th-    .nuulh    tho    v.n.<    pa^es 


m^^^^ .     mrwmnifmmmMi^^mimm^LMsmmm^^^ 


I  It'll  III,  y 


.I'.t 


.i 


|,rMil._'li  llir  .•-(i|ili;i'_'i|.  mimI  -l..in:iili  iiiM  Hi.    iiil.-liiir,  iii 


til.'  r.vl.lv  alka- 


|..|,     .  <<llll  Ml-     til'    uluri      ;ii.'    illlMI 

iiMiil.       'I'll.-   Iii.cilli   :i|i|".i 


Il,',|    c.ll.liri.MI-    l.iXi.lMl'lr    \^i<Y     il-    l'll|-t!nr 


,1,A,|.-|. 


I-     - I"    IKI 


..    III. Ill    ill.'    Iiiiii.  II  '>!    ll 


\i\   liil'i  ll-  \\:ill,  \^  nil  I  -|"'i' 


ll  1,1,  li  i.iK  .'  I,ir  111.'  h  iii|>li:ili.'  :i|,|i:ir;ilii-. 


I    I..III      llll-      I'-'Hl 

till  n,','    llii','n^li    ill, 


I     ill,  \     iiiii^i.il.     III    I 


l-.tr,:iiii    I, 


111'    I'rl.'il..!    iMiipliMli.'    t;laii.l-,    an. I 
ill.'    li--ii,-   aii.l    crLiiii-    lliMl    liavf 


II    ll,    ,l|,    ,|l\       jMlllll 


I' 


I 
ll'  a 1 


,1    mil 


ir,lii'ii-i I  111.'  |iiii.<" 


,',,|ilaiinii;.'    111.'    Iiacilll. 

,|'     illlrilinll    ill.  111-.  i\,'-, 


,1 


.,,1,  ,:ill,,ll   .,(■   til.'    ,A|i.li.ll..-    lli:il     li''^''    I"""     li:l.l   "I'll   "'li'l     I'MtlMi- 

,„,,i,.  i„.aiii  11.-,  iiaili,  niails    n  ■    .iLiiira-liainiii-.  tli.'  .,i..-li..ii  i-  iin|i.ii'- 

i";,„l    ;,,    I,,    |„,u   ill.'    iv,,l„,i,M..ii.l  ,    iM'liav.'  will.    l'.'lali.ii.   I.,  til.'    ^'ii-lri.' 

I,ii,,,,       I,    i,    In.iii    ill,.   ,inl-,l    III    ll.'   .'SlH'-'li'l    lliiit    ill.'  lv|,li,ii.l-l.a'illi, 

ul,i,|i    iliiiN,'   .A.'ii    M|".M    ImIiK   a.i.l    iiiiln.nt    iii.',lia.  u  ill    in,.i,'    na.lily 

|,;,-    ilir,,iit:li    till'    -Mill. I.  I iniiir,,!  llian  iIt  .'li,.|il'a-l.a.'illi,  wl.i.'h  ai'.' 

,-l„,ialK  -,'ii-iliv,'  1,1  lli.'ailiiin.ifa.i'i-.  A- a  inalhi' -if  fa.l,  Imlli  |.ni.- 
,i,,,|  ,.,11,1  ,Ai,,'i-iiu.iilal  .ill-.  rvMti.iii-  -liiA\  lliat  ill.'  lia.'llli  ..!'  Kli.rlli  ai'.' 
,.,.|;„iv,K  II  -Mint  III  III.'  -.'.'i.tiiin  .if  llll'  -liiii.a.'li.  -i  t''at  tli.'S  mav 
li;,\,.   till-    si-,ii-    uilli    tlii'ir    vilalily     |,ii-.  i  s ,  .1.  .'-|"  .'ially    if  a.liiiiN.'.l 

,,j,|,   ,.|,,,ii,  aili.'l,-   ..f  f.iiHl.       Til,'  IV,',    li.Mii-ii.liliin.'a.'i.l  li.'.ilal '  l.c 

i.ik,  II  iiii,i  ,',,ii-i.l.'r,iiii'ii  a-  .'MiliiiL;  a 


l.riiiM-   iiitlii.ii.'.'.       I'.|'-iii  lia- 
,M,|  1,,  I,,'  ;,l,-i.liil,ls    lianiilc—  fur  lln'  I'a.iHi  i^iiaii-  ami  Wiiit/'). 


\ll,i'  Kila-aln'  I, ,1.1    ll,' ii-li'al,'.|  llir  r.'lali\,'  l',■^i^lall.•.'  nf  ill.'  Iv|.liiii.l- 

l.anlli  |,,a.'iil-.  Siil/  -Imuiil  llial  in  a  ililiilinii  ,,f  liMJPi.liliirii'  a.'i.l.  •».:!  part 
to  IIHIO.  til.'  iiiiir..-..r-aiii-ni-  nlaiiinl  i  li,ii-  vilalil  v  fm'  llii'.-.'  ila\-.  In  a 
,1,1, nil. II  of  ii.'.l  |.arl  I.I  liliiii  lli.'V  u.'i-i'  fmm.l  .1. -iniy.  il  I'V  .-^t  ran-.'-  an, I 
Willi/  ..,,lv  ultiT  li.iiii  HMi  III  iliiv.'  Iii.ui'-'.  aii'l  Cliaiil.'iii. '>.-!'  an. I  Wi.lal' 
-li.,ur,l  ll.al  -lijil  a.i.lili.'aii.iii  uilli  livlnii'lilnri.'  a.'iil  ,liil  iml  t'lilinly  iiihilnl 
.|,v,.|i.|.iii.'iil  .iflli.'.iillur.'-.     Sli'i-ii  '  anil   Haiiil.up.'.'r,"  wli..  l-i.ik  ii|,  llic  .|ii.'S- 

li„n!..i,'w.  liL.u;-,'  i-Hii,'  M  I'l n.'lu>i.iii  Ihal  tli.' iinil.'.'li'in  atrnnl.'.l  l.y  tic 

l,v,lr,„li|..iii'  a.i.l  I.I  l!..  L.':>-ni.'  |.nr.'  a'j'iii'-:  '"  •  .'iitran.'c  nf  typlmiil-lia.'illi 
1-  v>r\   .l.iiililfnl. 

I  iji    a.T.mnl  nf  lli.'.inil,'   rapiillv  iiii'i'i'asiiiL:  iiuinli.r  nf  .'a,-,  s  i'.'|Mii'I,'.i  as 

l\|.l„,„l  ttilli.iiil    i -liiial    l,-.-i..ii,-.  ill,'  i|ii.'-Miin    ariM'-  uh.lli.'r   iiif.'.'liiin   ran 

n.'.'iir  tlir,.iiL:li  anv  mli.-r  lian  llian  lli.'  inl.-iinal.  nr  « lictluT  llu-  baiilli 
mav  iiiva.l.'  llii'  Imi.'Iv  l.v  |ia-ini:  llir.ni'j-li  lli.'  nnrmal  int.'stiiic  nviiIhhiI  laiismi.' 
aiiv  l.'>inii  in  thai  Ira.l.  In  n'-anl  In  iIk'  tiiM  |iii>>il.ilily.  th.'iv  i-  im  liimit 
at'|,r.'S.iil  that  -ii.h  a  mml.'  nf  iiif.'<'li.>M  ''an  fv.T  ."'.'iir.  Tlii'  <'as.'S  witlimil 
int.'Minal  l.-inii-  havr  lal.'lv  li.'.'ii  r.'vii'u.'il  l.v  <)|ii.'.  Ilf  .'nii.'lii.l.'S  llmt 
111.'  luiiiili.'r  nf  .'aM'>   is  inn  siiiaM  tn   jii.-lifv  tlu'  as.-.'rtioii  that   ty|.li.iiil-l.a.'illi 


'  Air/iire.H  fir  tni'ilfrine  r.rix' riini-nl'il' .    l'»>''.l. 

^  ZiilKchr.   f.   Ilwiii-lir,    H.l.  vii. 

*  .\i-rli'irr!<  ilr  /'/..;m'.. /,"/'' ,    1><>*7. 

i    \;.lkmaiiii\i  Snininhoni  Uin.    Wrtr..   Nmi'  l''..l'.'i\   Nn.   V'**- 

«  /-,'•".,.   /);,vv,'W<;^'...i,   H^,■^la^.   f-'m.  iniil.-i'  llu   .rn,-.'ti..n  ..t   M.'i'ii. 

'  /;,///.  ./..>,/..■.  llni,l.i,is  ll<.^/i..  \..|.  \ii. 


»  /,...',  .it. 


mi 


40 


ryriiniii  i  j-y/a; 


.•a.,  ,.v,.,-  ,.,wrr  llu-o,,..|,  Mn  mI,.-oI„i,.1v  u,,.,-,  i„„-ii„al  wmII,  vw  .„■„  i„  f„-,l 


1  i 


THE    MOST    IMPORTANT    CARRIERS    AND    MODES    OF 
DISSEMINATION    OF    THE  VIRUS. 

A.).,,,,^-  ,|„.  ,,,m,..--  ,.,  ,1,..  V  in,-,  water  i-,  M,T,,r,li„..  tu  ,l„.  ,,,,  ,,„ 
st.ir  „t  l.,M.wI,.,|n,,  l,v  (;.„•  tl„.  n,nM  i,„|,„n;,„..  Kv,,,  .i,„...  ,!„.,, Hi,.-, 
I:.n.-  w.lrr  i.n-  ,,l,,v,.,|  an  ii„|,.,n.,nt  ,-,;/,  i„  ,1„.  „,in,l-  ,,C  |„,,|,  ,1,„  |,i,,. 
"'"'''"■""■''''■■■''  l""''"i""  i'"l"'l'v,|„|,„„.n,  .,f,n,,-,  i„tiv,i„„-,li-...,-,.: 

\'"''    '"'•  '■'    ""■'■   ''^'^''   ''""'i'-    '"•"    -I'^.N.I .1    ,vn,l,T,.,|    .|„ul,.n,l    i,. 

•'^ '-■ '■    '"     '■'-''■•'     '"     '.M'l-i'l     tl'V.T.       Ka.-!i,.r    .Mlhurs    ,.-,„.,.i.,llv 

J)u|..v,    l;.„|,|.    M,n..|,i-„n.   .,.,1    (i.i.-in.,r,  ,.,M,,l.,-i„,|    ,|,„    i,,,,,,,,,:,,,;,. 

<•'  ".■"'•.  Ih'U.v,.,-  „i,|,  Iv  ,l„i,.  ,,i,,l,„i,.  vi,.u-  ,liv,.,„.,l  i„  ,„l„.r  ,v-|„.,,- 
Atnr  ,l,..,n    .1,,.  ,li-..ni„.„i„n„|-  , |i-„,,,    il,,-,,,,,!,  „ a.,r  u ,,-    nrnn- 

'^"""'  '"  *■"■''•'  l:i"'n,.,v  ....I  l.i,i„nn,.i-„.,.,-l,v  ,|,.  \,Ur,-  ui,|,  •, 
'•nt.ral  ,l.-,.n|„i„n  „r-,u:,l|  an.l  hn.,.  ,.|,i,|,.,„i,.-.  Thr  ta,.  ,l,a(  ,1,,-,. 
'■"■'^^  "'■'■'     '"'''    ■■''    '1'^"    'i'"'-  ..-t"itli-l;,..lin^r   ,!..    ,|,.ii,.i,,„t  kn,,u|„,|„,. 

"'  ''"■'■^'"-"  "''I-  'li-'^.-.  "ill  rv.r  rnuain  an  .xainpl,.  of  ..i,  ,„  ili,. 
Iiriiilirii. 

Thr  .v-„|,-  ,,f  Mi.u|..fn  l.a.l,Tinl,,^i..  in v,-t l-il hMi,  a!.va,lv  rullv  ,,,„- 
H.lnv,!,  |,,v,.  ,„.n„anrMilv  ,.-tal,li-l„  ,|  ,|„.  „;/,  „,■  ,,.,„,,:  ^„„,-  |,.,^.^, 
1m-|'1.-    |>.nni.t,,ia.l,,|„r    in-id,l    L.m  ,l„.  innunirraM,.  an,l    .M,v„„  Iv 

''^"'''''''''  '■'""'" -   =""i''  "l'i''l'  i'  M.:,v,-,rv,.  a,-,li,.,.a.Ti,.ra,Hl    ,li-.  ,ui- 

"■'""•  "f  '!"■  f.M'l'"i'l  vin,-.  1,  i-  k,,„wn  ,l,a,  ,|„.  watrr  of  .-,,■„,,„- 
I..'".l-.  ...el  -p.-,.,-  of  ,.„n,lui,-.  of  U.II-,  „(■  ,.i.,,  ,,,.  ;„„|  ,„.„,,,,i,„^  „|. 
|'<'...l-.  tl„.  h,l^,-«atrr  ,,t-hi|„,  „,,x  ,..,ntain  thr  lv|,l„,i,|-l,a,.lll„-  in  ■, 
l.v.i.;r-la...,  an,!  nn.l,r  iav,,ral,;,.  ..,„„li,i„n>  n.MV  rym  prnni,  it-  linll.,.,- 
'l'V.I„|,nn.,t.  That  .In-  ,l,.v,.I.,,„n,„t  i-  i,n|...,ill,.,|  i„  fl,„vin.  „at,  r 
<l'''"  'I.'-  |HV-,.n,v,,f  a  i.iv,,.,n,|,fant    ni,rnl„r  ,,f  wat,.-l,art,Ti.,  or  pntiv- 

l^.''t.vr  a^„u-    i.  ,.a,,Ml.l,.  „r  ,|,.-,,.„v  in.  ,|„.  |,a,.illi.  i.  na.n.allv  , 

tr.-„l„.I„rv    „,    tl„.  .•„at,.--tl,r,,rv,"l,nt    ra(l„r    thn,i-h,-    in,|,o'rlant    .laf, 


(''I-  r\|,lalniMu-   th,-   v^,i-ial.ilitv   ,.t' 


the  («(iiiiciici,   tiir  severity,  and  the 


(li.-lfiliiiliMii  .,r  ihi.  ili-,-!-,.. 

■ri"'  f-.-..i-  i..  wl,i,-h  water  ,„ay  ..tvo  as  tl...  mean<  ..f  e.mvevin.n  ,1„. 
>."M-..~  ^ern,  to  hnnia.i  h.'int:- are  in  .l.taii  -,.  ..xt,vn,..|  vva,  ial.l,.  that 
''"'•■    "^'""■"    ^'"   '■"■"    '"•   ""'.ti'me,!    i i-    |,'.„.,,      |.:v,,.v    in.livi.hial 

'  />;.  rr..,./„„,/..,.:„f,.,...„.,„„  t.,,,i„..„.  m ■,.,,._  i„.:,„i,,  ,^,,-, 

■   \,.lk„.n„„\  s„, „„.!„„;.  u:,.    I-,„7r,  N...  .-,:!. 
'  (ii-xiiii,,,,,//,  .l/,/,„„,//„,„i,„.  S.  L'T-O"), 


J"n<)l,()i;y, 


41 


.:,-..,  ,n.!,niir,.r  ri,i,l,,nir,  .•aiviullv  M,„li,.,l  i„  ,l,i,  ,.,,„n,.,.ii,,„  ,.x|,i|,i,.. 
i"<-iili„r.UHl  ill  |..irt  ii,NV  (•(,M(iiti..M-,  aii.i  tlic  iiiMM  vaiir.l  ivlations  witli 
"tli-i-  l.iH^^  KnouN.  '1-|„.  H,u|,l,.-t  mimI  .vriainly  tli..  nio-t  iV,.,|nc.it 
-MviimiK,.  ,nnM-i-  in  intiTii,,,,  thi'mmh  <lriiikiM--vvatcT  and  ]i,,.ii(l  a-< 
Nv.ll  a..uli,l  arli.'!..,  of  (on,!  iliat  aiv  j„v,,a,v,l  Mi,l„„:t  a.l,.|i,at,.  .t.ril- 
'"^"'""-  ^^■•"'■'  "-'l  '■■"■  'l-aii-in-  ami  ntli,,-  ,l,,n„-ti,-  i.uriM.s.s  can 
"•"'"■'">■  ""'  lH-r|,aiaIr,l  iVom  <liiiikin--wal(i'.  CihI.t  iIk >(■  ciiviim- 
.-ta.icc-^  alM,  Ili.av  i,  ,|i,v<r  ,.,■  in.liivrt  .<|,,.,ilic  r,  mlaluiualiuu  of  liiaUdaLs 
that  uaiii  fiitraiiri.  into  tlic  (lii;-,-livt'  tract. 

■I'lii'  iiianncr  in  whvh  th,.  Matrr  in  .|n,>ti,.,i  I,,.,...in..s  rontaminatcHl 
I'.v  llir  ,|,;i,.,.!i,,ns  ,,f  tv|,l„,i,|  |nlirnts  natnrallv  cxliibits  tl„.  {,rr,,,t.'>t 
•liy.THty.  It  n,ay  nr.iv,.  ,!„■  :^rnn^  ,|ir,.,,l_v  from  tlm  pati.^nt  or  from 
priyy-urlls  or  ,r.~|,.,ol-.  or  thron-h  artirlrs  .i„-,a-ti..,ily  .■.,ntaininat<-,l 
"•vi.l.nlally,  or  it    may  In'   intlvl,,!    in.linvtly  l.y  invvi.ai.s  f-atnrati.ni  of 

''"■  •"l.P''''iit    rartli  with    Ihii,!-, tainin-  the  ocrm-.      Kveii  in  the  j.n'- 

harl,aioloj,ri,.  ,„.rio,|  ninMcr.,n-<  .■archil  ..h-,  rvations  bcarin-  upon  tiiis 
pniiit  urn.  ma.lc.  amon-  whid,  a  nnnihrr  .-ouM  \,v  ,lin.-t(.l  \n  iih  rnnark- 
ahlc  poHtivrnr-s,  in  th..  miis..  of  lin.i.l  an.l  of  (;i..tl,  a-ain.t  tl„.  >imp!e 
|"il,vla..!iv,.  th.^.ry  ..f  Mnr.-hi>.m  an.l  hi.  pr<.l.v,->,,rs  an.l  >n.v..~M,rs 
in  this  .■atc-.,ry  arc  iii.^lii.l,  .1,  Cr  in-tan.-..,  tl,,,,,.  ca>,.s  i,,  uhicli 
w,ll<  that  f.)r  a  l.,n-  tim.'  w.iv  .l,ni.,n-trahly  .-ontann'Mat..!  with  tho 
..v,all,,u-  fr.Mi.  .vv-p.,.,!.  ..an,,..!  n..  ,,r  only  ovn.ial  ha.l  ctf.vts  np,,n 
the  c.n-nm.T-  of  the  wat.T,  an.l  ..niv  ;,ravc  ri-.-  t..  th,.  .hv,  h.pmcnt  of 
lyph.ml  f.v.T  after  tii..  wat.T  ha.l  b,.,.n  -p.vili.-allv  inf..i..l  with  the 
.l.Jc.'iion-   fr.)ni  a   i-asv  .it'  lyph.ii.l    ti-vcr. 

In  the  natur,'  ..f  things,  wli-inf.rtions  are  .•..nhn.-.l  to  a  f,'«-  ea..^.  or 
t..  Mnali.a-  .>r  Iar.v,  h.,n<,M.pi,l.,ni.s.  L,..s  .•..mm.miv,  wh,.,  ]i.|uid 
ar...l.--  .,!    lo.,.l    n^.l  .,n    a    lar;n.  -.-ah.   ,a<,  f.r    instarw,,    n.ilk,  or  >aM 

""'■''"  "'  ' '""■'■  '"'■'■'■•-•''  '•>  i"..u.s  ,,f  Nvat.T,  will  a  lar-.r  nnmi„.r  of 

'•'^'■^  ^"''^' •'■'■*'>■  *'•'""  "•'"-      ^'"  -■nviv  inilvti .rur.  in.iir.vtjv  if 

' 'iMvtIy  n.f.ri...|   ....nxw  tl»-  .li-.,,-..  t.,  ..iImt   lo.-aliti.s  wh.r,.  n.'W 

l'">    "t    H,l.rti..n    .I,-v,.iop.       Kn.h.n.i.s   .,f  ....nsi.l.ral.le   ,.xt..,t   an.l   evn 

'I'"''' <li^tnl.ution    ar..    natin-allv    n,.,re    r.a.lilv    ean>..l    thr.,,,.-!,    the 

""'■'■""'<li^"i".i  ..f  hu-,T  an.l  Mnalh  r  rivrs,  str,.am's.  l,r.,.,ks,  an.l  .prin,.. 
'!"■  '■'■lation  of  th..s..  t..  th..  .l.-v.-lopnu.nt  an.l  .li.-..nm,ati.,n  of  tvplw^id 
I'V.r    was    ..stal,h-.h..l    mn.h    later    than    ti,at    of    w.lU.      .Manv    Jan^e 

"''"'"' -^    ^^■''''■''    ^"    '•"■    l"'''-''',t    .lay    ..an    l„.    .|..linit,.|v    tnu'.d  "t.,    tliis 

"""1"  "<  "nVin  ..ere  i.r  a  l.,n.r  tin,,.  n-,.|  to  snpp.„.t  ..th.-r  th,..- 
"'-.  th,.  pyth,.-,ni,',  th,  atm,Kph,.ri,.,  th,-  ,r  rfh-th,.orv,  ,,r  th,.  jrroim.l- 
wal,.  Il„„r.v.  ri„.  InC.n.n,-,-  was  ma,|,.  ti  ,t  prior  to  th,.  ontl.n-ak  of 
the  ,.p:,|,.m.,.    tl„.re  was    no   lyph.,i.l    pati.nl    thruu-hont   tl,,.  ..omnnmitv 


12 


rvrii'iii)  ri:\'i:i:. 


or  in  its  viciiiitv.  I  low  clx',  iIk  iclinv.  (■iiiil<l  llir  di-ciM'  li;ivr  iiiixii 
t  xrcpt  tliroULlll  ailtiiclllll(ill"i;-,  local  dcA  rlii|iui('llt  ol'  iiitrctidlis  liKitlils? 
W'ci'c  iMil  i-|>(<'iall_v  tlic  coiKlitiiiii-  of  till'  soil  ami  tiifir  variatidiis 
iiiiilti'  till'  iiithu'iicc  (if  tlio  Liriiiind-watcr  (ifci>ivc  as  an  cliold^ri,.  t'actr.i'? 
It  was  oNcriiMikfd  that  the  \^atci-\vays  r<iii\('yiil  llic  sjKcitic  |)(ii-iiii  iVntn 
loiiLC  dislaiiccs  ;  lliat  liiixiks  and  streams  niblit  Ix'  intiricd  tlii'dn^di  their 
triliiilario  ;  ami  lliat  ii|inn  I  nyir  water-ways  slii|i~  were  capahlc  of 
inqioriinLr   tlic   iiiliclinns    niatirial    iVoni    rinintc   pdint--. 

'I'viiliuid  fr\rr  liccanm  nio-t  \\idcly  4i--ciiiinatc<l  in  larjrc  cities  in 
wliicli  tlic  \\atei'n-ed  liir  diinklnu''  and  other  lionic-lic  ])nr]io>c-,  ini|iei- 
ti'ctlv  or  not  at  all  llltcrcd,  was  olitaineil  from  larL''"'  stri'anis  that  con- 
stanllv    scrscd       ■■    i'<'<'c])tacl<s   iiir   the   contents   ot'    the  t-owcrs  oi'    tlicsf 

cities  thel,    -elvi  ~  or  of   tllo-C  of    neiuhl  lorillL'  cities. 

All  ol'  the-e  fii'toi~,  it  nin-t  he  cn\]iha-i/ed,  to  counteract  the  influ- 
ence of  tli(>  few  reiiiiiininLT  hut  jicr-ir-tent  o|i]ioncnl-  ot  the  theory  of 
t\|ihoid  t'e\i  r  as  I'  wat'  r-hoi'iii'  (li-ea>e.  arc  in  no  w  i.-e  hypothetic'.  'I'lio 
demonstration  ot'  1\  phoid-hacilli  in  the  water  ot'  well-  and  stream-  has 
ol't<ii  licen  made  direeth.  and  their  iicr-i-icnce  in  thc-e.  as  has  liccii 
j)ointe<l  ont,  is  midouhtcd.  'J'hat  the  hacilli  have  not  liecn  found  in  the 
.-u-|iecied  water--u]i]il\-  in  cvcr\-  endemic  or  c|iidcnn'c  i-  not  contradict<iry 
of  tin-  view.  Thu-,  it  has  lieeii  reipcated!)  oli-erved  thai  in  a  ^dveii 
localil  V  the  t\|ihoid-l)acillu-  \va-  e\  idciuly  ohtaiucd  from  a  certain  >onrce. 
l-'.n'.irts  wei'c  iiia<lc  fiirtiier  to  olilaiu  |iroot'  that  a  tiieus  of  tyjihoid  i'ever 
had  exi-ted  at  a  hi'jher  level  ;  hut  when  examination  of  the  v.ater  was 
undeitaken.  the  |>rimar\  foeu-  of  iid'ccti.-n  had  ah'cady  hccii  extinirnishcd. 
I(  ,|,;iv  :i|.o  lie  readiU  conceded  :it  it  i-  hy  no  means  always 
po--ilile  to  demou-tratc  the  jh'cm m-e  of  t\  phoid-haeilli  <'Ven  in  water 
that  -till  contain-  iheii,  l-l-]ieeially  civally  eontmninated  water  <'on- 
tains  numerous  oiher  mi<a'o-orL'-ani-m-.  which  may  render  idenliiication 
of  the  t\|ihoi<l-l.acillus  dilllcnlt  an<l  even  im|io--ihle  even  t'or  an  experi- 
enced oh-i'rvci'.  It  -hoiild  he  noied  (-jiecially  that  the  di-trihutiou  <if 
the  hacilli.  particularlv  in  connection  with  <■(  naiu  iinin-  of  pollnlion,  is 
hv  no  mean-  imiform.  Thev  are  often  attached  to  i-,,latcd,  irrcc-nlarly 
di-lrihiited  panicle-.  -.>  that  only  extremely  timc-con-umiuL''  and  pain  — 
takiu-  inNc-iiuaiiou  of  lar-e  amount-  of  water  will  yield  approximately 
tru-tworthv  re-ult-. 


The  literal -re  .>!'  a;i  ccinitries  from  the  hcL'iniiiiiir  of  the  nineteoiitli  ccn- 
turv  until  rc'(  iit  lime  cmilaiiis  a  lar'-c  numher  of  reports  of  epiilcnncs. 
.some    -ixeii    uitii    full    detail,    iiiducc,!    In    infectiim   of  wells.   sprinL's.    nnci 

streams.     Limitations  ot' s| e  alone  wil  not  permit  extended  consideration  of 

tlie>.'.        iicv  liMv<'  heen  cnlleelcd  iu  part  li_\  M  u  pliison.  t  iiel  I.  and  ( i  riesiniTcr  ; 


j-rnoijicv. 


43 


•ilso  Kiflii  riiicislcr  '  ;uiil  IJioniicr  '  liiivi' irivi'ii  iiuiiicriiiis  liil)liiii.'r:i|iliic  rcti-r- 
i-iM  >s   ill    till  ir   ui.rk-,    uliiili    .~o    !ii-illiant!;.-   nii<l    il(  tiiiilclv  tstjililit-lKMl    tlie 

(Iririkiii^'-ualrr    llii \<    an    illiislralion  of  uill-iiit'ictinii    tlic   tiilldwiiifr 

(iliM'i'valinn  iiiav  suftii'c :  In  llic  farlv  part  of  tlic  m'\ cnticri  I  Ircatcil  a 
iiiiialnT  t)t'  tv|iliiiiil  I't'vur  palit'iiis  liviiij:  in  a  suliiirl)  of  Hfrlin  upon  a  larire 
o.statf  wliich  iiiclii(if<l  allll'l^t  IIMIO  inlialiilanls,  wlm  were  crowilcd  ti)L'cllifr 
in  small,  ]W)'  v  vi'iililatcil  riMinis.  My  iiivcstiiralicins  disdosiMl  ijiat  at  the 
sanio  time  ai  it  .HOotlicr  patii'iils  were  iimliT  trealnieiit  citliiT  at  linnif  or  in 
linspilals.  I-  iirtiier  impiirv  revealfd  that  liu'  water  ilerived  from  the  only 
wrll  upon  the  phlee  (the  L'eiieral  water-i-npply  had  not  yet  been  extended  to 
this  locality  I  wa.s  jrreatly  polluted  by  oriraiiie  material,  wa.s  liirhid,  and 
iifeiisive  to  the  .-iense  nt'  smell.  A  year  previously  the  water  pre>ented 
.similar  eharaeters,  and  the  cinise  was  fiinnd  to  eonsist  in  a  conimiiiii- 
cation  hetween  a  lar;.'e  eess|)ool  and  the  uell.  My  opinion  that  such  eoii- 
tamination  ot'  the  water  by  the  eontenls  ot'  the  eess|)<H)l  still  existed  and 
must  be  the  cause  of  the  typhoid  fever  v\as  met  by  the  statement  on  the 
part  of  responsible  iiulividnals  that  in  the  previou.s  year,  when  the  water 
was  similarlv  contaminated,  there  !iad  been  no  typhoid  fever  in  the  coiii- 
inmi'tv.  Purther  invesiiL'ation  disclosed  that  this  was  correct,  but  also 
revealcil  a  comlitioii  which  explaine<l  the  apparent  ditfcrciice  and  eon- 
viTted  mv  suspicion  into  certaiiitv — namely,  that  four  weeks  before  the 
oi'currencc  of  the  lirst  ca.ses  of  tvplioid  fever  amoiiLr  the  inhabitants  of  this 
section,  a  bov  had  arrivi'<l  in  the  jilace,  in  wiioni  .symptoms  of  typhoid  fi'ver 
.soon  appeared,  and  from  whom  two  children  in  the  family  with  whom  he 
lived  were  infected.  There  vius  thus  no  loiiirer,  as  in  the  previous  year,  only 
L'encral  |iollulion  of  the  well  with  fecal  material,  lint  an  ailmixture  with 
speiitic  Lrerms.  the  cAseiitial  condition  for  the  development  of  the  disease. 
.\  most  instructive  instance  of  di.s.seni;natioii  of  the  poisftii  tlirouiih  the 
wat<'r-su|>ply  is  furnished  by  Liebermeister.^  In  the  villaire  of  I.ausen.  in 
which  for  a  loiiir  time  only  isolated  ca.sep  of  tyjilioiil  fever  imported  from 
liasle  had  ocrurred,  and  for  seven  years  no  ca.se  at  all.  in  the  yeai  1x72. 
anionic  M)()  inhaliitants.  l.'iO,  almost  17  |>er  cent.,  were  attacked  between  the 
months  of  .Vuirust  and  ( )ctoher.  The  epidemic  set  in  so  abniptlv  that 
almost  100  cases  occurred  within  the  tir>t  three  weeks.  A  number  of 
piTsoiis  alsi>  who  were  only  teni]iorarilv  resident  in  Lau.sen  were  attacked. 
Caretul  iiivesliiratioii  disclosed  that  all  of  the  houses  of  the  villaL'e  that 
ol)tained  their  water  from  puni|)-wells  were  exempt  t'rom  the  di.sea.se,  which 
invaded  onlv  those  whose  water-su))plv  wiis  obtained  from  rinmini:  sprint;^. 
With  reiiard  to  these,  it  was  determined  that  a  small  brook  that  constituted 
their  source  wa.s  contaminated  bv  the  overflow  from  a  ces'^pool  and  a  manure 
pit  allai'lied  to  a  house  some  distance  alxive  the  viUatre,  and  in  which  there 
had  been  four  cases  of  tvplioid  t'ever  duriiifr  the  months  of  June.  .hilv.  and 
Aii^riisi. 


■I,/,,,.. 


iCit.'.lhv  !,i.-li.T!,..i-|.T:  Zii.  K-.lnv.Tl.  /);.  Tii/ii 
Hnllr  „.  S.  ill,  J., In;-  /\,-/.  Iliillr.  IsTI.  N,  liiui-.Mi.  r.'..,-  A./lnl,,,;-,,-  ,/.v  Tu,,/,i„ 
fi''f/fnnina/in,  Ziirirlii-r  [)i-"rl:tli"n.  W'ititfi-iliur,  IHT'J  i 'l"\-|)tir>  in  Wiiit'Ttliui- 1.  ("■'in- 
piiP"  ;il-M.  rcTiiiTliiliLT  till'  -illni'  ipi'liiiiir.  \Vi-ililli!Mili.  ('<;-f:-</i"iiilrii^hl .  f.  S,-/ni\  A'  ,-Jr, 
IS.--'.  N...  ■.':;, 

■  iiirniiiT,  /,...-.  fit.  Wi  i--ll.i^',  ■■  I'll.rr  dii'  Tvplius  F|ii(lcinif'  zii  Klt.Tli  in  von 
IsT-J,'  /),■„/„■/,.  A.:/,./.  I.lu,  M..I..  is::'.,  IM.  \ii..  .■^.  :il.'ll,  KuclnMinici-ter,  ■■  |).t 
H.-iri)K\r,l(-,l,,!|'T  Tvphu-.  1H7-J  7M.  ■  .1".,  /-.'/.  /•>;./.:..,  1|.  ft  I .  A  KnMniOin, 
(•;rns/„.,„/,;,:hl./   S,-/,,r.   Amle,   i^T:;,   N",    id.      Conine-lie,   lli,,/.,   l^T.j,  Nu.  H. 

■'  /,i.<-.  cif..  S.  04. 


II 


TV  rill  III)  I  i:\i:i:. 


All  iii^liri'i-  ol'  till'  ilr\cl(i|)iiHiit  1111(1  ciiiilciiiic  (li>iriliiiii(iii  of  tv|i|i(iiil 
''■"•■'■I'""  :i  i:i;-v  .-cai,  tV..ni  .i  iar-r  .-Ir.-aiu  l^  I'liriii^licii  liy  liic  roiMliiions 
liiat  picvailcl  in  I  lainliiii-L'  in  llic  .iirliiics.  In  ih,.  \,ar>  1X.S5.  !««(;.  I>,s7, 
and  l»N.  i:),MI|  |„i--,,ii>  u.-iT  alla.'kc-.l  l,y  I\  pliiiij  \v\,r.  witli  1214  (Icatlis! 
A>  i>  l.iKUMi,  Ilauiliur-.  uiilil  tlir  i;Trat  ciiolrrii-ciii.U'inic  (IfiiKin.!.  .1  cviii 
iiHirr    uri:<-iill\   than    lyiilioiil    ih,.   ii(i',»ity  ot'  a  cliauiic  in    it.-  ilMiiv-, 

<lii-iviil  ail  ni'  ii>  uaiiT    fur  ilrinkiii_'   ami  liiiini.-iic   piirpoi-i'.-i  I'l  ii,>  river 

iillir,  uiiici,  \\a>   r.,iiv(yiii    inioili,    lioM>ics  uiitillciTii   and  i'i!i|      .t-dforall 

'""""iiii<'  iind   ( inici-cia!   |>ur|i(i.-f>  wiilmiit   prfvious  di>iiit;Mii,iii.      A  i si 

the  only  water  liltcrcd  was  tliiit  iiscij  for  ilriiikiiiL'  and  culinary  |mr|M.,-.rs.  I.iit 
it  Ha>  dont'  wiili  M])|iarMtiis  tliul.  as  is  now  \iionii,  \va.-,  \<v  rca-iiii  of  its 
dcfi'clivf  coiistruclion.  calciilaltMl  ratlicr  to  cxcrl  an  injiirioiis  di'.  ■  .  than  to 
i^iiLscrvc  the  |iiir|.osf  tor  uliicli  it  wa>  «ni|iloy(d.  Ev.n  at  that  time  1 
ciintciidcd  that  the  df\ clopincnl  of  the  f|iidfniii'  was  alli-diutalilc  in  I'nalfr 
dcirref  to  the  olivioiisly  specitieally  inf.Ttt-d  \\attT-sii|i|ily  than  to  all  other 
intlueiMcs.'  I  ha.-ed  my  o|iiiuon  especially  upon  the  !irraii;.'t'ment  of  the 
seueraui  .-ysteni  of  1  laniliiirL'.  the  ediiteiii.- of  which,  poiireil  into  the  Kliic. 
\yere  eapahle  ot'  eaii.-iiiL'  intei'tion  of  the  driiiUinp-waler,  likewise  ohlaiiied 
from  the  Elhc,  liei'aii:.e  the  point  at  wiiich  the  sewai;e  was  emptied  and 
that  IVoin  which  the  water  was  ohlaineil  were  not  suflicieiitiv  separated. 
K-lK-cially  was  it  in  th.'  hi-hcst  dcirrcc  prohahlc,  and  even  demon>l  rated 
liy    llie    cxpfrimems    of    .-iinmoiids,    that    the    relliix    wave    indnced    wilii 

•I"'    '1 1  tide  of  the    Kl'.ie   I'arried    the    inalerial    eniiitied    tVoin   the  -ewers 

np    to    a:.d    heyoiid    the   ]M)iiit    from    which   the   water-supply   wa>   ohiaiiied. 

I'roni    liic  iinit()rm  distrilmti f  typhoid  fe.cr  throiiiilioiit    the  enlire  inner 

city  also  it  was  concluded  that  a  iiiiitiirmly  distrii)uie(l  carrier  of  the  poi-on 
was  opcrali\e.  This  could  .-carcely  he  aiiythinir  else  than  the  waler-supplv. 
]-".\eii  in  ihe  eyes  of  the  most  fanatic  ailhereiits  of  the  locali/ation-theorv  the 
coiiililioiis  ot'  the  .soil  and  the  ;j round-water  could  not  .serioiislv  lie  takeii  into 
consideration  in  ti  city  that  for  a  lonj:  time  had  lieen  provided  with  a  model, 
extensive,  intricately  raiiiityinir,  and  excellently  workini:  s\slein  of  seweraire. 
Additional  positive  evidence  was  found  in  the  fact  that  in  the  iiei<:hl«irin<.' 
<'ity  of  Wandsheck,  iinmedialely  contiiruous  to  Hamlpiirir,  and  wIkks,.  jnhalii- 
taiits  live  under  identical  extermd  conditions,  and  the  same  conditions  ot' 
.soil,  climate,  and  weather,  there  were  only  a  few  cases  of  tvphoid  lever 
diirinj;:  the  same  period.  Tln'  only  point  of  ditf'erencp  helweeii  the  two  cities 
was  in  the  water-supply,  'Waiidslieck  ohtaiiiiiii:  its  water  not  from  »lie  Ham- 
hur;:  supply  and  not  from  the  Klhe.  Still  more  characteristic  was  the 
existence  of  an  almost  com|ileteiy  iinniiine  collection  of  huildinirs  within  a 
portion  of  the  city  of  Ilamliurj.',  in  which  t\plioid  was  as  .severe  .iiid  a.s 
olistiiiate  as  in  the  remaiiiiiiLT  parts.  The  Iiitrracks  in  that  section  occupied 
hy  the  ,S'venty-sixtli  Infantry  lieirimeut,  which  contained  in  its  voiiii^-, 
viirorous  memhers  material  in  most  marked  de<.'ree  pre(lis|M)sed  to  the  disease, 
rcm.iined  free  from  the  epidemic,  w  ith  the  exception  of  a  few  oliviouslv 
ini|)ortiMl  ca.-e>.  It  was  not  connected  with  the  ;:eiieral  water-supplv.  hut 
received  :dl  of  its  driiikiiiL'  and  other  wat.T  from  a  well  upon  the  premises. 
The  .soil  and  i:roiiiid-waIer  theories,  however,  at  that  time  so  thoroutrhly 
dominated  the  minds  of  those  in  authority  that  my  opinions  and  recom- 
mendations' fell  upon  deaf  cars.  .'<iihsei|neiitly  the  relations  in  (pie.sfion 
were  invcstiirated  hy  Heinke,  and  my  previously  expressed  views  were  f'llllv 
<ontirmecl    and  aniplilied    Uy  a    larL'e    imnilier  of  carefullv  estahlisheil   facts, 

1  /),„/„■/,,    ,„,,/,     If,,,/,,,    isss. 

2  />.„/.>,-/,.   l',o7./,,  /.  ,,_//;.„//.  i;,s„„.//,,-i/.y,fl,-,,,'.  ItJ.  xxuii..  11, .fi  :; 


irrioi.'x.y. 


V 


Tlif  riiilici-  iiil'rifiii  1-  lliul  uilh  cvcrv  l! i-liiir  liif  Water  ul' I  iic  Kliic  lii'tuciii 

till'  I  "lint  'ii  ili-cliai-'jr  nt'  the  >cua-c  ami  llic  .-nnrcr  (if  >ii|i|il\'  fur  thr  water, 
anil  even  lar  lieyiiml.  runlaineil  an  im-rea^eil  niinilier  uf  irernis,  was  nrnnveil 
Iteyonil  linulit  liy  l)iinliar.'  'I'lieii  Iteiiike  ileinuii>tr;ile(ll)V  lalilt'?  the  fact, 
to  wliieli  '  hail  alrcaily  ilirerie.l  attenlinn,  tlial  tlio.-i'  |)iirtiiiii>  iif  llie  eilv  lliat 
reeeui-ij  iluir  waler-.-n|i|ily  frnrn  the  ciiininnii  suiiree  were  aliiii)>l  iiiiiiiirnilv 
utiiickeil  liy  tlie  e|ii(leinie.  w  bile  tiie  inii.-t  |ieri|iiieral  ili.-irids  i  Winleriiiiile, 
l']|i|ieiii|iirf.    ami    llnnii.   wliii-li   al    tlial    time   iliil    net    >liare  f(|iiallv   in   the 

lile.-.-inL's  of  till ninmn   .-n|i|ily.   exhihiteil   riirres|H)ii(liiij.'-|v  and  >trikiiiL'lv 

fewer  eases.  'I'he  elearot  riiiilirrnalinn.  however,  is  atlonlfil  hv  a  eonsiilera- 
tion  ii'"  the  ennililions  in  llamhiirL'  .-iriee  the  lime  <  Miiv,  1  •"<!•.'!  i  when  the 
source  of  waler-sn|i|iiy  was  removeil  a  eonsiileralile  ijistanee  further  ii|)  tiie 
stream  ami  when  the  water  itseif  was  sniijeeled  to  ai|ei|iiate  liltralion  hefore 

it  reached  tl il\.      I'or  the  years  |.s!t4  and   I.H!).")  the  inorliidity  of  lyphold 

fever   was   4(i'J   and   olT    res|ieelively. 

The  followhiLr  t;ll)le  of  lleinke  is  more  eloinient  than  words  ; 


Niimtitr  lit"  I  iiflcs. 


NiiiiiliiT  uf  liuiitli: 


isst 

1-s.-, 
1  sm; 
iss; 

ISSS 
l.HM'.l 
lX!)li 
IS'.U 
isirj 
IS'.l.-l 


Ali^iiliito         Tl.  llXli.f  till'       Ali'iililtf      T.I  linn' I'f  the 
iiiiiilliiT.  |ii.|.iilatl..M.  uiiiiibir.        j.i.|.iiliUi..n. 


l((."i;! 
•-'17-' 
:W.K» 
(!.>!:{ 

:il72 
l.-i:«i 

11:17 
r.in 

HI'.U 


4  (;."i 

S.(M1 
.'iSil 

L'.oi; 
l.M 


Ids 
loo 
;!:!:! 
44(i 

*J7r> 

147 
IL'S 
:.'o:; 
101; 


isnl 
IH'.l-i 


■haliu'.'  ei  l!n-  >..iiri'f  ..f  *il|.l.I\  .-iii.!  illlr...lii.ti..ii  cf  [ill  run., n. 

4i;2  (i.7ii  :;7 

.    .    ,  ...     ■'i!l7  (!.'.";  .'.7 


(I-J4 

(i.:;4 
(i.i;'.i 

(I.!  10 
(I.  .-,4 
(1.41 

(l.-'ii 
o.L"J 
o..;.'i 

O,  IS 

0.00 
o.on 


It  is  further  iiiterestini:  and  distinetive  that  more  than  one-tenth  of  the 
ca.ses  of  tyj)hoid  fever  in  llandinrL'  noted  in  the  years  l><!t4and  l.'^ii.'idid 
not  occur  in  tlie  area  sn]i|ilied  with  I'xnd  water,  lnit  were  observed  iiiMin 
ships,  on  which  it  devehips  in  consei]iiei}ce  partiv  of  infection  of  llie  biiire- 
waler.  partly  of  importation  troin  eisewliere.  Ueinke  proporlv  einjiliasizes. 
besides,  the  danLTcr  of  ships.  10  which  typhoid  tev<'r  is  -o  iniliirenoiis.  with 
relation  to  iidection  of  the  river-water,  and  also  the  water  of  other  navi- 
iralile  streams.  The  IliunbiirvT  epidemic  well  ilhisl  rales  the  operation  of 
a  larL'i'  vicinns  circle;  Iidection  of  sewairc  with  typhoid-bacilli,  convevaiice 
of  these  iiy  ihe  tlood-tiile  to  the  sonn-e  of  water-snpplv.  distribiitinn  of  the 
infected  water  llironLdiont  the  entire  city,  as  a  result  rapid  multiplication 
of  the  lyphoid-baciili  in  ihe  contenis  of  the  .s(.wers,  and  ihrouLdi  the.-.e  a 
])roirressive  inci-ea>e  in  the  number  of  bacteria  in  the  water-suppK'.  It  was 
not  until  the  year  lf<'X',  that  the  nnt'ortunate  circle  wa>  interrnpleij  by 
chaiiL'itiL'  the  place  for  dischar;j;e  of  liie  sewaLTc  ami  the  erection  of  suitable 
liltralioii-|ilants. 

Ill  aiiilitinii  to  water,  various  liipiid  articles  ui"  DmhI  iiavc  alreadv  iiceii 
desiirnated  a<  laiviers  of  the  typhoid  contaiiiiiin.  ( )f  tiies<',  liiilk  is 
di  s,.|-v  iii^r  ,,('  ,.vp(.ci.tl  |.|insi<lerali(in.  Milk  is  a  source  of'  infection 
iiatiifally  luit    in    tiie   s'.ine  way  a«   in  the  case   of  that  from  tiiber'-iiloiis 

I  Cit.'d  liv  Kiirikc. 


T!  ■ 


46 


t 

i 


TYPiK'Ht  rrvii:. 


-•It!  !  Il  !■!  ^        \(    !i. 


annn.N.  ul„.,v  n   i-  mi;,,,.!  ,iin.,.,ly  i,v  li,,.,,,,  a,„l    .,  ..„nlnl,„„.-  ,„  ,1„. 

'''"'"""^""•"    "'■    '"'"■'•■■ul.M-.        Ty,,l„,i,i     ,;.v,.r     i,    „,,,un     u„h 

'■'■'■'^'""^  ' '"rin.min.U.      Tl„.  ,,;/,   ,,r  ,nllk  .-  ;,  ,-nm..r  ,.r  ini;.,,!,,,, 

'•' '    ■■'-'"'I'l'-    ll-l    '••■  ual.r.  .I,iv,-,h    .,,l,„iv..|    ui,|,  u|,i,.|,    ,„■   ,„|.,,. 

"' ''■'■'"'   "   "^'"''i'-    i'-    iM.inri..n~    :„.,jvi,y.       Tl,,.  tn  |„.n,  n,v-    nf   ,h,. 

I.M     .u,.u>.v-l,v.    ...,.,-    |,:,v,.    I.Ml    , f„„    -h,,u ;„     nnIL     liK,.    ,|„. 

7'"  '-"''1''^  ■""'■'■'"'    ^"    i'~    - ■'■'■    •■'■    -    n~    |,„in,    „r,.„ll,.,,l ;,v 

''"'""-''    "■    'li-"'il'"n ,.a,|    ,„    ui,|,.-|„VM.I    Ji-.„Hnati (    ,v,,|„,i;i 

'"^"'   ^""'    ^'^"    '■'-'■    '■■    -'"^'1'    ■■'■   -'■"    -■    n,..,.,.    ,.x„.„-iv,.    ,.,,i,|,:,„l,.- 

"'■"'    '"    "'"    ""'""■''■''    -"1    i"    >l„.  '.,i|,,|    -,.,„.  ,nilk    i.an   a.!,,,!,-,,!,!,. 
'"'"~''''""^''   ^""'    """■""t    ""'li'""  I'"'-    ivi.l,..i,l-|,a,.illi,  ul.i,.!,   ,,.,,.,1,,    i„ 

'"■'■''"'■''   """^■•- i-'l"'-   l"ll„.,v|„.,- •MIal,,l,-,.,-valiMn-„n|,.i,n'   i;„ 

'"■"■'■    'I''"    'I'lrry  ,|av-.  ai.l.   ul,al    ,-    ,.-|„.,.ialN    ,la,„,.r„„v    iImv    ,i , 

'"""'■   '■"^'-"'■•" •^""'    'I"    '"■•    '■i'^'"--    >Ih.    milk    in    ,„|„.,    .v-i,,.,,,    ,„,,, 

l"'''""'~     ■''-'■v^"i"n-l     in     a|,|„v,.iaM,.    ,k^o,,.,..       I„     ,,||     „  „1U,  ,|„„,,,  ,„, 

yl""""'-""^l''"'''"'^"''l"'-'""'ill^>l--an,....,-i,.„f,.v,.n(-.n„„li,i,,,l 

""    ■'^"'--  '-    '■'■I"'"'l^    l"f'">i fll,..    l,nlk    ,.r,nilk    .u,.,,li,,|    l,v,|„. 

l;;-'"l"'-"M..r,l,Mril,n,i,,n.  ,l,v,,n.l,  u,.ll-ua.,.r  ,.,-  -prin^-uafr  „,  „  |,i,.|, 
""'"■'^  '"  '"'l"''''l.v.  llH.,l,;i,.,-,i„n-  Inan  ,v|,l,„i,|  |,a,i,,„.  |,avr  ..ain,.,| 
';"''^""'-       ■^'     'i""-    'I"     '•-'-    "f   >1h'    .li-,.a^,.    l,av..    I„.,.n    tl.nn,!    •:,    -, 

'''^'^""■"  "■ 'l-'^in".  t^M'  alu.v.    tl„...,,n,-,.„C,|,..   M.|,|.lyin,    -prin.-, 

:iii'l    at    "llicr   tinii-    in    t|ii.   (laii-\     il-.lf. 

,     '■''"■    ^'"■'■'•■''    """'"-   "'■  ""'■'■'' !■  "'ill^    a,v    varion^:    Lilnti,.,  „i,|, 

""■  '"''-"'I  "a" '■.  1-V-,  I'valiun  an.l  tran-|.„na.i,,n  \r  vr-.j.  rin-,.,|  ui,l, 
■'"■''    "^"'■'■'  '"■   ''"■"'■'    infrriinn    tkn.n^l,    ,l,r    lian.U   ,,f  niilk.r-.    .Irak,-. 

MTvant-.    an.l    n,!,,,-    ,„.,■-,.,-    u  I,,,    |,avr   .■mn,.    i niari    «i,h    lv,,|„,i,| 

|.:itMni~  an,l  ll,,!,-  .k/p.-tinn-.  an.i  uh,,,  Ik.vIml'  nr^kvtr,!  ^niial.k.  |„v- 
''■■"""■"^-  ''■■'^''  ' ^".^'■'1    ""■    ^<n,i~   ,lir,v,lv  tuth,.    ,„kk,-,  tlir   n,ilk     „r 

Natnrallv,  ,,th,T  arli,:,.  ,,C  r,,„.l  ,,|„ai,„..l  fnm,  .lairk-  an,|  niilk- 
"l-l""-  "'ay,  HniikiHv  „,  n, ilk.  art  a-  ,l„.  .-am,,-  ,,r  jntl.-lion.  P.ultrr 
-|"-ially.  ,n  whirl,  1 1,  in, -'  ti.nn.j  thr  ha.illi  t,.  i„.,si.t  Cr  .«,.ntv-,,nr 
'law  an,|  ,|„.  ,li„;.,-,.nt   kin,i~    of  ,.|„.,..,..  in  ul,i,.|,  ,|„.    ;,a,.iili  n,av  ,m,m~I 

''■'""  """.'"  ''"■'■'■  ''•'>■'  '"  a.-nnlan,T  ^^i,l,  tl„.  n,.tli,„l  uf  .nannliu-tinv, 
may  act    in    tlii>  «a\-. 

A^  rai-iyas  li,..  M■^vuUv.  .v|.nrts  „f  niilk-inHrlkm  wore  made  in  En-lnnd 
t"  l""n,..  «l,„.|,  an  ,.x„„mv,.  Ii„.,atnn.  .k.v,.|n,„.,|.  .\>  un  instance,  a  ^.v-t,' 
|"l''""'"t  l.vpk,,,,  ,,.v,.r  i„  ,i„.  year  l.s7:;.i„  the  ,iis.ri,,  of  S.  ( icor-^eC 
llanovrr  N|aa,-,,   Mar.v  l.-hou...    I |„n.  tnav  l,e   n,enti„ne,L'      It  s.„.n  ,h~vei- 


Mi,l,.,i,„i„|  ,1,.   Mu,,v.    /'„/,,  ,/,   /  .1,.,,,/,  ,/,    M.,/  ,    IKHI. 


/.'«•.   ,■//. 


lliDLuc  y. 


|"''l  lli:it  .■..■r\Miils  an. I  .v-iMrially  .•liiMrcr,.  «l 


(lir  milk 


iriiri,  a  cr-iaiii  u 


■ll-k 


I'l  were  in  llii'  liaLii  iif  ,:riiik 


'niiin-Mniic]-,  uho  Has  cm  iii,-i,mI  uiil,  || 


ii'ivMi  iiairv,   u.i-c    allark.il    in    hir; 


47 


MID 


■('  i]Uiiiliir> 


MolliHIL'    >u.-|ilclol|.s  ;    ai 

I'lirllicr    Id   csl'lilish    ll 


III   a   >ccon 


!!■  in\(-iiL'ali(iii  lit  I 


ll.    uiiii   narliiil   a 


lli.iv.i:      II, 


If     llarml^■>^ll(■^ 


•  I     1 1 


lik 
Ik     I, 


II-  ilairv,  tnuinl 


lie    ilii'il     -liurllv    at 


I'Miil    Ilic    |,ciially  of 


I'    rcsiill,    cmlfaviii 
iiiiwlf    |iarlaki 


Irruard    fnini    a 


t-slalili>limriit    ua.s   I'losnl     aiiij    il 
iliArl. 


Ilii' 


ii>  i\|i(  Timfiii  uiili  1,1,    lif,..  iria.>miicli 
■vir,-   alia  -k    ut'    ly)iiioi,|    t'.'v.T.      Tl,, 


nliH'h    III! 


i'lnriil  «a>  i,.,u  ,-.|i,,uii  |,,  I,,'  a-  11,1 
lis    \,s.~c|s 


I'lilrmir    M..,ii    .-II  I, Ml  I, '1 1.       Ii.v    „ii„l..    (,f 


airv   ijian    nns,- 


'"iili'iit>,  romiiiiiiilial.'ij  Willi  ill,.  .„,il  iiimamiiiaUMJ  I 


lie  ucll  .villi  ill,,  waitr  tV 
'i"l    jii'oiialily    also   ,liliii,.,|    ij,, 


ii| ^^  liirli  ha 

till-  ilairv. 


Iiri-ii    lln-DUii    til,.  ilijcciiiiMS  frill 


|ari-iit  iliiii;.'--li,.a|> 


II  a  case  of  tvplioiij  t 


<-vcr  111 


aiiii'i-on  '   olis,.r\i-ii    numi-i-oiis 


I-  i.f  lyphoiil  ti-\fr  in   DiiLlin  i,,  ,1,. 


I---  I.I  a  ^iv,-n  I  iMrii-t  ilial  i-,.,-,.iv,.i|  ilu-i,-  imlk  from  a  ,-,.rIai,i  ilairv.  uliil 


llii-    lioilsi's    that    il,.ri\,M!    ih,ir    milk 
fXi'lllllt.        It 


111   mlirr  r>l.-iMisliiiicm.s    r,-Miaiiii-,J 


I't.      It  a|,i„-an-,|  that  in   th,.  ,laii-y  lir„t  m,.|ilioii,.,l  inf,.,.! 


iml    result,.,!    throii-l 


.Ml 


aihl 


if  Iviihoiil   t; 


in  of  till 


iiiiiunL.'   the   ininati's   of  I 
mil 


i-si-rili,',|    \- 


i-vir.      All   e|ii,leiiiii'   ohserveii    ii 


Niiiiilt.     Is    nil, resting:,    havinir 


oci-iineii 


iiilleil    mil 


wi.   prisons   of  .^tra.ssliiiri;,  ius   a  result   <,f  |h,.  ns,-  „f 


fi-vir  h.-ii 


K.       I  Ills  was  oliianieil    ti 
-iirreil,  ami   tlie  ili.-ea.-e 


|ilai-e    HI  wliieli  ea.ses   of  H| 


n>ni  llii>  -oiinv  was  cut  olf.      The  etiol. 


ileii 


soon  ;i^  ll 


,1 


11-  sll|i|,|y   of    iililk 


iiiatenallv  sireiiLrll 


iieil  liy  til,,  tael  that  ll 


111   nil   ex|ierim,iit,  ,.|it,  of]'  fi-o,,,    ;.r,.|i,.ral 
eN|>iise,|    I,,   i,|,.nii,-al.  llioroii-l,|v  ,-,„ilroll 


nstanee.s  ot'  inilk-iiit 


(; 


Ho 


eeiioii   ari'   r(-(-or< 


ii-ne  inl,.ri.r,-lation  oi'  ||,is  ,.pi,|,.||,i,.  |.^ 

'le  persons  iii\o|v,i|  were  almost,  a.s 

ten-oiii-se    with   oth,.]--,    ami    w,.re 

eoinlitioii.s.      Further  iiistnielive 


•reaii   et    !•' 


Ii-il   mIso    I,v    Alm.|iiiM,'    Roth.'    |;,.i,.| 


Ali   Col 


leii,     ami   others. 


Ill  ei.iitra--t   ^^iti|  milk,  ivri.-iiii  .-irtieh-s   ,,f  .Ji-inl^  ;|,.,.  j 
tlie  laity  as  ,-a|.al.le  ,,f  .jimini-liinir  the  ilano.T  nf  inf,.,., 


are  111  repute  aiiiiinir 


i<lea  the  siis|)(M-te(|  \\at 


mil. 


Wit: 


ntr 

1   tills 


er  IS  111 


(ir  al,-n| 
nii'inliil 


li'l,  <ir    !h,'    ii-e  of  ;ih 


ll'll'-s    lit'  e|ii,lemi,.  liiixe,]   with   f,,;,_   ,,,,f];,p 


Wit  I 
t;ir  a-  ,heir  el 


■"'i"'i''  lieverao-e-    iii^tia.l  of  water  is  n 


1  'vh-n-ii,M.  to  t,.,.,  aii.l  i-otr.-e,  it  may  |,n,,(lv  |„.  state.)  that 


leime  eoii-titiuiuii  is 


;"tt'e,-t 


eiilleiriie,!    tllev 


lixiii   the   typhdiil-iia.-iiji.      With  reo-anl 


Nave    III)  (lejeteri,,iis 


exjieniiaii 


l<  iif   l'i(-k~  have  s| 


iii.Lr  a  eertaiii 


ile-I 


HIV-  n  that  while    tin 


ile-lriii'tiv,.  ,.fr,.,  I      ,„„|    ,1 


til  -jiiritiiniis  !j,|ii,,ps,  the 
y  are  eapah],'  of  excrt- 


llleail- 


SI)  active  ;is  it  i- 


nut   i|e~triivci! 


le   tyjihuiij-l); 
11)11111  cJKilcra-viKriiis.      '{'he   1 


illi.  tl 


IIS     IS     ll\-    IK 


111  iinliiiary  whit,-  nr  reil  talil 


an   liiiiir,  and   at    t 


thereiiii 


ulilitimi    o 


e,    serv(>   as 


exerted    lui    l)aeterieid; 


lines  e\|.ii    lali'i' 
a    priiphy  lactic.       F.aL'-er 


ia<-illi   are  freiierallv 
e-wiiie  earliir  than  ai't.r  luilf 


iiiie   to  water  eaniiot. 


ll     etrci-t 


lieer  anil    other   lii^ht 


within    a    rcaMinahly    practi<al    tinie^ 


'  .s.,.  Ii 


n.u.-iril,'!  .■!  Tlmii 


/)..,/»■/,.    r, 


■I.  p.  .-,4. 


f.  un:  <i 


/""",'/.    /)'<».     Ilallr.     ]v 


Hn-lni.  1.1,, I.    W,„-h..  1 


s,ii,,IJ,,it..  H,l. 


n'rrkhl.    r.    /,.    .V. 
■  \r,-h.   f.    II,,,,..    \\,\. 


'  Her.  ,n, 


lh„l  .    li.f 


,1/7.  ft  ,1.-  l',,l. 


,-.  ru,„-  (inirsk.,   1HS7,  BU. 


■■"«'V.,  1s;<2. 


.^^Sr.? 


48 


/')  rilnlli    I  I  VI  II 


iKarlv  lialf  mii  lii.iir.  Tlic  aiiimi  i.T  -iri.iiMri-  alrnliolii'  1)|.\  crajj-cs 
[laMllalU  i-  iMiii|ial':ili\  '  K  lll"|-c  |ir.  .|p  illlin  il.  Tlill-,  I'iik  ■  il  .-i  |\  i(  I  i'lr 
liar'lli  ti.  lie  ilc-lii.v  I  il  ill  r\  !■  \\  lii-ki\  w  illiiii  liv  (■  iiiiniil.  -.  W  licii.  Imw- 
I'Ml',  all  ii|nal  aiiHPiiiil  "t'  walii'wa-  aildnl,  a  liall-ln'iii-  (lap-iil  ImIoj-c 
llii-  I'l-iilt  \\a-  liTMii'^lit  alii'iil.  The  la-l  r\  pii  iiiu  iil  iiidiialr-  ll;al  al-n 
tlic  -Ir^nL:!'!'  luci--  ami  wim-,  i-|iiriall\  tin  -wnl  wiiii-,  Wi'iiM  lie 
liiiriiialilf  'aIiIi  itIik 'iir  to  lluir  di -I  nicl  i\  t  t  tli  ri  iijion  I  In-  l\  |.|H,ii'- 
lia.-illi. 

If  ilir  cciiiiiiici-cial  I'llaliiiii-  uilli  I'dri'tiiic  Idnlliir  arliclc-  I'l'  limd 
arr  -nlpjiclcil  to  cld-c  -i  iMiiiii\.  (iaiiiiir-  -iinilar  ti>  llm-c  llial  alliinl  iIh' 
ll-c  III'  milk  will  rcadiU  ipiiiiinr  a|i|iai(iil.  'I'lir\  arr,  lio\\(\(r.  li-- 
lllidi  !■  ((iiilrcl.  iMiail-i  till-  ri.iilaiiiiiiali'pii  i-  i.ftili  ai  ridililal  anil  dilli.  nil 
ul' diinnii-ii-aiinn.  and  not,  a-  witli  milk,  ^\-l(lllalic■  and  oil  in  ir|ii'atcd. 
and  litraii-i'.  aiTiifdiiiLiK  .  I'atliii'  i-nlali  d  ra-i  -  n\\  niMirr  cii'tain  riiTiini- 
,-tani'i--.  widcK  di--iiiiinatrcl,  -mall  and  I  In  itI'oit  li--  (■(iii-|iiriii  pii-  tmi 
(lr\rl'i|i.  it  i-  ijilitr  rliar  and  li\  iin  niraii-  -illliriilil  U  a|i|il'i'i-i.itid  llial 
t\]iliiiid  ic\i-f  ma\  lie  di--i  ininatcd  tVnm  i-lal  ili-liiiirni-  tl'nin  wliirli 
vi'Licialiirs  and  t;i'irii-,  (~|irriall\,  lin\\i\ii-,  iViiii,  Irttinr,  and  -iinilar 
artii'li>  i^iiii'falU  latcu  in  an  iininiikrd  -tab',  afr  olitainrcl,  it  tln-c 
ai'tirlr-  111'  rin-rd  I'l'  -|ii'inklril  \\illi  intirtrd  watrf.  Nut  li --  ini|'iiiMaiit 
difiii  inl'irtiiin  nt'  tln-r  arliik-  nl'  li'nd  liy  t\|iliiiid  |i.itiiiit-  wlm  live 
in  tlir-r  r-talili-limriit-  iif  liy  llm-r  in  altindaiiri'  n|Hin  llic  |i:itiriit>. 
'I'liat  lifrad  and  rakr  and  in.iny  uilin-  artirli-  raliii  withuiit  lii-iiiL''  :iL;':iiii 
(■(inked  111'  liratrd  inav  lie  a  Miiifri'  iit'  daii:;i'i'  ill  a  -iinilar  nianntT  dnrs 
lint  i'ii|iiii'i'  t'nrtlirr  rl.'ilinralinii. 

It  lu'cil  niilv  hi'  imti'il  that  \  (■ui'talilr-t;nrili-iU'r>,  lic1n|-i'  LrniiiL'  to  niarkct, 
siiriiikli'  tlicir  uan'>  uitli  uatrr  in  nrdiT  to  Lri|i  tin  in  rif>li  ;  and  rmi-iilcni- 
tion  slidiild  lie  'jivrii  In  till'  r>|M'rinl  liaiii:!  f  il  tliiM'  aif  ti'.'iiis|iiii'lcil  ill  larye 
nnKiiiiils  liv  \(>,-rls  ii|inii  lai'LT  >lrr,'iiii>.  wliirli.  a^  ur  have  h'CIi,  arc  mi  tri'- 
(|iiriitlv  inti'ili'il.  |-'inallv,  attciitinii  >!iniilil  kc  ilirntril  In  tlii'  cnliiiitinri.'i 
thai  I'l'i'vail  in  lIu- dwi'lliiiL''-riiiiins.  ihi'  .-ah -r(iiiiii>.  ami  l  hi- >liiraL't'-rnnii;- nl' 
ilrali  I's  in  vr'jrlahli'-  ami  a rl icIi'S  iit'  rnnd.  .ami  the  nianmi  in  uliich  tln-r  aii' 
criiuiliil  tnL;iiiiii'  ill  ha-riiuiil.-  in  larLM'  ritirs  iiiid  rninmiiiiiratr  dii'i'i'tly  xvilli 
mil'  amalii-r.  'hi  arrniinl  not  alone  nt'  ty|i|iiiiil.  hiit  al>o  of  otiier  iiitei'tioii^i 
ili-i:i,-i<,  .-hiiiil'l  >anitai'v  su|iervi.-ioii  and  ni:  iilal  inn  of  lhe;-e  ennditions  he 
more  llini'iiiiudi  than  ha-  liilhertn  heeii  eii-lmaary. 

Natni'alK'.  lv|ninid  li-Ner  ma\  de\elii|i  ill  any  |iri\:ite  dwcUiiiir 
tllfnlltili  dil'ii'l  nr  indireet  int'cctinll  nt'  artii'le-  nl'  i'nnii,  illld  lie  cnllVeycil 
cl-i'W  lii'i'e,  till'  laller  niein'riiii.''  e-]«'eiall\'  it' the  meinlier-  nftlie  family  nr 
the  -erv;ini-  take  |iarl  in  nniviiie-  the  |ialieiit  and  al-n  in  dnine-tie  wnrk, 
e-|)eeiallv  ennkil'L:.  'I  he  eiiiiditinli-  are  Iim-t  -erinll-  ill  till-  eiilllieetinli 
aiiiniiLr  the  |ioniei'  ela— 1-.  lull  al-nainniiL;  tlm-e  lieller  -ifiiated  almn-t 
ilieredilih'    lllilies   will    he   dnlie    I'rnlll   \WUlt    nt'   knn\\  ledp'    aiul    nwillt:    tn 


I  I  I'll. Ill,  y 


49 


iiu|.r..|Mr  .•iiTMii..r..iii,.|,t-.  AUm  in  lio-|.it.iU  .li-~,iiiin;iiioii  of  tv|,lM,i,I 
i\yr  .M-,.|ir-<  if  tlic  lu.-l  --rni|„iluiH  ,■■.„;■  \,r  iiut  i;lv,n  to  il,,.  ,■!,  Miiliiir^^ 
"''  ''"•  I'lli'iil  AUi]  lii-  \  icinily.  ,i,  ucll  :i,  t,,  tlic  .li-iiii;.,|  i,,),  (,C  'Ij,.  .|i.. 
'■'"'-'■-■  'I'l'l  il'  ill  :Hl'liti"ii  ill.'  atlri„|;iiil.-  Iliil  I,,  ,,l,-,rvc  llic  ino-l  ri-i,| 
l'iv,.iin|,,n-.  M,,-|  i|„,|-,,ii::h  .li-inrcriioii  ,,f  il„.  |,:i,„|,  ;,|„|  ..l,,,!,!,,^,^ 
-111.  I  |,iv\.  iiii..||  .,(■  iiui-.'S  rii-ni^r,.,!  in  i|„.  .Miv  ,,f  |v|,|,.,i,|  |,:iti..|it.  tV..m 
■'''''"-  '"  •'"•  'IIV,  '-|><''-l:ill,v  tl,.'  i;..liii-  .,f  „ti„.|.,,  ;,,,.  ,,-,„,. i:, IK- 
iiii|'"i'''iiil   < -i.l.r.ili.iiis    ill    ilii-   ...nii.vti..n. 

Kv.'ll      illl|..ll-      III.'      I..ll,|-     .hi.-.-,.,.    M,,|       to     >.|„.;,k      ,,t'      lll..M>      los      fllVDMlMv 

Mliinl.'.l.  Ill,-  |.l,\>i.laii  .-aiiiiol  lak,-  lur  -i-aiil,.,|  llial  llinr,)!!-!.  .li.-iiiH.<-|i.iii  .,f 
III''  Ikiii,!.-  uill  l,r  |,nir|iM,|  aa.l  a|.|in.|.iial.'  |,r,-.'aiili.,ii.-i  u  ill,  rc-ar.l  l.i  lli,. 
'■'Il'''  "'  ill''  '■l"lliiiiL'  "f  ill.'  all.-n.laiiN  uilj  l„.  ,,I,.mi-v.-,|.  Tlic  i\.-s\vM  of 
in-ili.r.- Ml-  mn.-.'s,  in  -nin-  iV.mii  ih,.  h,  k-l„.,l  i,,  tl.c  .liuiii--r.n,i„,  t|,iiik  of 
'•1.111-111-  ili,.;r  ,-l,itlnn-  ,,r  ua-liin-  llaai-  liaii.ls  .-,,  tli.,r.)iiL;hlv  a.'*  I.,  t-x.-lu.l,. 
111.'  |in->il,iliiv  ..f  .•.iiiv.Aiiii:  .li-.a.-,--.i'iii.-  I,.  arli,'l.-s  .,f  f,',.M[  an. I  .Irink. 
liiMilh.'i.'iil  .'ar,'  III  .li,-i„f,.,ii,in  i.-<  .•,ii.aii,lv  llu-  i,i...-I  fn.|u,ait  m.'aii.'^  I.v 
"hi.'li  I'liVM.'!.-,!,-.  ,aii,|  run->.-s  a..|uii',-  lli,.  .liM-a.-...      Wuh  iv-anl  Mil.,.  lan.M' 

i    liav.'  aluay-  i„..u   .-iiu.'k  uilli    ili,-la,l    lliat    .-.-inviallv  n.u   ■-...    ili,.,-,-! 

t..r..  tli...s,.  «!,.,  ipaii  .•anl,'.,-ii,-.-  ,,r  la.k  .if  .-kill  .1,,  ,i,,"t  „Ii>,t\,.  iI„.  n,.-..- 
sai'v  |irfcaiiti,iiis.  arc  iimn;  .■nniiii.iiilv  alla.-k,',l  lliaii  .il.Kr  aii-l  iHitcr-traiiicl 

lll|l'>,  s. 


TRANSMISSION  THROUGH  THE  AIR. 

Rcli'l'i'ii.v   ha-   ali'.'a.ly  l„.,-ii    iii.i,!,.   t.i  tli.'   i'.lati..ii  „i'  tli..  air  t..   llic 

' •'-'"'"  "'■  '.M'li'ii'l  'i'^ir-       It  v^as  ,«,int,'.|  „nt    that  ili-.'ininati.Mi  ,.f 

till'  .'"iil.i-iiiiu  iliniii-h  lli...',ii'  ;~  |,.,v-il,l,.,  w|„.th,.r  II...  ,.:i,.|.i,.r  |„.  in  a 
iii"i-t  .'..ii.iiti.ii,  ..!•  ill  a  .ii'v  -lal.'    in    llic    l^irm  .,f  ,ln-t.      'I'li,.  ti,vt  ni...!,. 

"''  iii'';'''i""  n'.|iiir,.-  litth i>i.|,i'ali.in.       It  u.ml.l  |„.  ,,|KTativ,.  aliim-t 

('\''lii-iv..|y  in  (h,'(.v,.ni  .,fa  -imiy  in- ,,f  ini;.,.,,.,|  (|nM  aii.l  it.- aci.l.nlal 

";""'■""■'■   ill'"  til'-   I Ii"f:i    sii-,M'|,til,|,.   iii.livi,Iii;il.      r..-.<  ,'.,niin,,iiiy, 

iii.lili;.|'..ni  tini.l-  in  tli..  lin'in  .,f  -|,ray  nii-lit  .'.im  th.'  .'..nta-imn  atta.-h('..l 

'"   ''"'"    ''"■   ■'    i-i'l'Tiil-l.'    <li-tan,v.    a    |H,-il,ifitv    in    liiv.ir   „f  wlii.-j, 

La-nii.''  ha-    |in-..Mtc.|  cvi.lcii.v.       Far   v  .•.iininuniy  in    |ii;i,.ti,v  tli<. 

po8«il)iliIy  .,f  .li-,.ininali..ii  ,,f  th,'  .•..nta-inm  l,y  i.'arti.'h-  <,f  ,|n-i 
must  1,,.  tak.'ii  int.,  .■..n-i.l..|'ali.,ii.  |;,.f..,',ii,-,.  ha-  a'il'ra.lv  I,,.,.,,  nia.j.'  t.. 
th,'    |M.r-i-i,,,..,.,,f  ly|ih.ii.l-l,a,'illi    in  a   .In   -tat...      Th..  '.'iiti-an,',.  „f  the 

';"'"•'-' li-'iimml.'l    thniii-li    th..  air  u  ill  .„.,nr   iin.|;.nil,lv  tliniiii;!, 

iiiiialati.iii.  Ih,.  ;.-,.nn>    iMin- ,I..|„,h'i..1  tir-t    in  th..  „ th   aii.rtli..    ii.im.. 

Kntiaii....   int.,  th,.  ImmK-  an,!  tli,.   I.l..,..l-tr..aiii,  li,,u,.v..r,  |.i'..l,al,lv  takes 

I'''"' ^y  tlir'.ii-li  til,.  ,liu.,..-tiv,.  tra.'t.       \Vh,.th..r  .ntraii.',.  nf  tli,.'  I,a..illl 

iii:iy  tak..  |,l.i.-,.  al-,.  thr.inoh  th,.  n.-pirat-.n  a|i|,araln-  i- -till  a  .|,.|.:ital.l(. 
'lii,-ti,.ii.  It  i>..,.|'laiii  that  ..ntniii,.,.  l,y  ,hi-.  ,..,,,1,.  w.„i|,i  .-..nMitnt,.  th,. 
.■.\,','lili..ii  (iiiR.|nii'.tyi.li„i,i  ■.').     .\,.v,.|'tli,.|,.-s.  th,.  ol.-,'i'vati,.i,-  .,f  i;n..!i,i,.r, 

'    ■/'/,.-,.    I';ili-,    |,S:i(l. 


no 


7)  riinin  1 1:\  i:i; 


wliicli  riirni^li  cxiMTiin-'Hl:!!  ivi.lni.c    in  r:i,..r..|'  ilil-  iiichIc  .>!'  iut'r.liMii. 

:ur  vMirllix   dt' ci'ii-'Klrnilinii  Mini  riinliniiMliiiii. 

>,-,,  ■,.  cMii    lie  -:ii.l  iVi'in    llii'  |iiiMlit    |Hpilil  nl    \  icu    VMlli  n-ind    l"  llf 

,11-:  '.111111:111011  ..r  lv|.lini,l  l.-v.r  ll;rnu-li  ill.-  iiir.      lis  ,■../-   Iia>.  Im'c ■  :i  mlmv 

MiLonliiiMlc  nil,   ii'i  .■nin|,;ui-..ii  Willi  lliMl  ;.--i-iu-.l  lu  il  in  .■Mi-|i.T  liiiio.  ulim 

c^pfciuliy  111!'  iii'|i.-rl.cl  <lili;niili;Ui 4    l\|iliii>  :iiiii  Isplmi'l  tt\.T  iiivcrd 

ti.is  view       Allli.iuuli  il<!irin>.'  pr.vjiU  in  llii.- <'onn>'ciiuu  m  the  |irrsiiil  .Im\. 

MIKltJKT     .ill- 1 1.1-     vii'U      llll:-     ll"l      Im-,1I     whnllx      (I  llnl  llillr.  I     11 1     lill'     mill.!-     df 

iniir.-iiril.'  iiHJivi.liiMU,  uiiiri,  lor  ;i  Ion-  limr  ■  ..nMiliil.il  llir  >tn.i.'j.^l  -ii|.|.nri 
for  ilu'ilcH  irinr..fil,r.li.".'niiniHion  of  H  |plioi.l  r>\.  r  lhron;.'!i  tlu'  iiir.  n:iiiM'ly. 
lliMI  air  <-onlaiirni:il.Ml  l.v  |.utrl.|  Mlll^lalM.■s  i>  <a|.al.K'  of  (•aii>ln-  lyplioi,! 
I'tA.r  .lirccllv,  or  al  Iim^i  of  ;nnn.:  a>  lln-  larrii  r  of  llu  coniaLjiiini.  Al  lln' 
linx'iil  ilav'il  i-iiolonuir  luMllial  i.ulri'l  Mili>lani-c>  of  llinn.-clvi  >.  t-|..' 
rially  llii-  il,M'oin|.oMiion-pnK|uri-  of  t, ■,-,>.  (■on>liliil.'  tin'  cx.alini.'  iiL'inl  of 
typlioiil  fovcr.  an. I  ihr  opinion  of   Hial.l  llial  llir  s|fcilic  1\  plmiil  ;.'.rin  iiniKr 

I'l,,..,.  , liiions  liii.l>.  al  lia>t.  il- >-|«i'ial  |.al>iiluiii  lias  al.-o  liccn  aliaiiiloiuMl. 

'lo-.lav  u.'  n(|iiir.'  ll.o  'lii -iralion  of  oiIh  r  .  lio|o-ii-  factor-  llian  foriiu'i-iy, 

«l„ii,'\vitli  111.'  a|.|..araiMV  of  typliol.i  liv.r.  llu'  .liMo\,ry  llial  fonl  air  from 
an  a.lja.vnt  <v->|h,o1  or  oilior  fo.ii-  of  |uilritacl'on  cnlirf.l  lli.  il«.lliiio  «as 
.li'.nu'il  fiillv  ^nllic'ioiii  lo  i\|,lain  llir  lausc  of  the  oulWrrak. 

It  uoiiU  natiirallv  l'"  oniiio-  too  far  to  jniioiv  riitiiv|\  ilio  lari:.  nuiii- 
hor  ot'  <:i-o<  r.|.ort.(l  liy  ivIiaMr  early  iii\  r-li-ator-  in  wliioli  il  ua< 
l„.ii,A,.,l  ijnit  llir  cuiita'.rimii  \va-  (li-oiiiinaloil  1>\  <'oMlaiiiiiialr.l  air. 
Soino  of  ilii-o,  it  caiinol  lie  iloiiio.l.  aiv  -ii-(v|ilililo  >>i'  -caivoiv  any  oilier 
into.-j.rolation.  Moiv  ivml  lii-lori.-  of  -inillar  oliaraclrr  uoiiM  iialii- 
rally  1m-  jiiil^r,.,!  |,y  an  onliivly  ilitVnvnl  -tainlanl.  Al  tin'  pn-.nl  day  it 
^\oMlcl  lio  iio.v-ary  to  ,1,  nion-tnitc  that  tl.o  air  in  ,;iirMion  was  lailon 
with  aoliv.'  tvphoiil  .ontaoiiini,  ami  thai  the  . -011.1111011-  for  its  niov.- 
tnc  lit  an.l  the  ,-ntiMin-i-  of  the  ihiI-oii  into  the  ho.ly  wiiv  .-|M-rially  favor- 
alilc.  As  an  iii-lam-.-  of  the  lack  of  i.rn-i-ion  in  c-arll,  r  nh-crv  atloii-,  a 
|MTs..nal  .■xix-ii.-n.v  ami  tli.'  lii-tory  of  tu.i  (-i.i.l.-inics  iVoiii  the  well- 
known    work   of  Mniehi^on    will    siilliee. 

\t  the  he-innin-of  th.-sev.-iitles,  in  a  h.iar.lin^'-srhool  in  Herlin,  in  wliieli 
f,  vonn-  |»-i>o„>  ,M-eu|fie.l  a  lar-e.  well-sitiiale.l  heilrooni,  1  of  these  «as 
atlaekeJ  uith  s.-vere  ivphoi.l  fev.-r.  an, I  was  >eiit  l.y  n.e,  on  a<-<-oniit  ..t  his 
..onii.ani.Mis,  all  of  wli.ln,  reniaine.l  w.-ll.  to  ih.-  hospital.  Oftieial  exaiuina- 
lion  of  the  ease  ,liselo>e.l  the  preseli.e  upon  on.-  wall  ol  ill.-  ro.Mii  ..l  a  nioi.-l. 
otn-nsive-sniellini.'  sp..t,  resiiltin-  fn-m  a  l.-ak  in  a  hrok.-n  .h.-.-har-e-pipe  in 
Iht-  wall  Ni-ith.-r  In  the  li.aise  in  .pi.-sti.ni  n.n-  in  th.-  a.li..iiini'.'  Ihhim-.  n>  I 
was  ahle  t.)  .■.invin.v  nivs.-lf.  lia.l  there  heeii  a  .-ase  of  lyiih..i.l  fev.r  wuhiii  a 
hm"  time.  N.-verthehVs,  the  pipe  ami  the  ^|M,t  upon  lla-  wall  ha. I  L'  l.e 
e,.nsi.l.-r.-.l  as  the  sonr.-e  ..f  the  .lis.-a.s.-.  My  ..l.j.-.-ti.m  that  the  remainni-  :. 
inmat.-s,  .ifalHiiit  tin-  same  a-e  aii.l  e.pial  pr.-.lisp.iMli..n.  ha.l  reniame.l  well, 
an.l  that  the  ilis.-as.-  of  tlu-  sixth  initrht  have  heen  ae.|iilre.l  els.-wher.-  ironi  a 
(hir.l  sour.-,-,  ua.-  r.-.-.-iv  .-.1  .-nlv  with  a  .sympath.-ti.-  shni-  .ifthe  slmnhh-rs. 

\l.-o.  tin-  well-kn.i'.Mi  and  ini,  h-.pmt.-.l  epi.h-ini.-  .if  lyph.n.l  fever  m  the 
K.-ho..l    for   ho>s    altaehe.l   to  the  Coh-hester   I'liion   in    l.umlun'   loses  most 

I  Scr  .Mun  hi.-. .11,  /'.<•.  '■''. 


H 


irinl.ni,  y 


61 


"f"   il-*    '*""'■ Minn'    I'lin-fiil    scniiiiiy.       In    ilmt    in-^lmicc    iimiiv   of  ihe 

|>ii|.il-  ill  a  >.|ir>,i|r,,..in  iIkiI  i-iiiiiiriiiiiiinl, d  willi  ii  m-«it  liv  iiicaiiM  nt'  tin; 
rliin.ii.y  «ti-.-  :ill:irk«'(|  uiili  a  sfVirc  aciilr  ili.-.-a.-r.  wliirli  wii-.  ino>|  iiiliMiM! 
iiml  a|i|>ran'.|  (•arlii->I  in  ili.w,.  M-alr.l  inari'sl  lli-  (i.iriini'V.  .Miin'|ii„,ii 
li.a.l  iHi  .loiil.t    iliai    the   ,l|.,as.'  Has  iy|,li,,i,|    r.-v.r.  ami  llial  il'  n-.-iillcd    Inini 

ll Iialaliun     u|'    injiinn,!-    -aM-"    ir.ini     tli.'    rlniini.y    m    ,|iir>lii>ii.         I'ho 

iiilialalinii  a>  llic  .aii-c  uT  ilic  (li...'a.M-  i.-,  Ir,,ni  MiircliiMiii's  (icrripiioii,  iii..>t 
|ir>il>aMi'.  aii.l  alriio>i  i-i'i-|aiii  fmiii  tin-  nlijiniM.  jKiiiit  nt'  \  i.w  ;  hm  ||,,,v 
couM  Muit|ii„,ii  kii.iu.  uillioiii  M.iih.' am  ..t'  ili,-  |,aliiMil-.  ilial  lli.'  ,li-,'a~,^ 
was  lv|,li()i.l  fv.-r/  Onlyrnuii  llic  fact  lli  t  llic  srli,„,l-iii>|Hc|,,r  inroiiu.Ml 
''I'll  'li^'l  111  llii'  "|ii;il"ii  nf  ill,,  alien. Ii'iir  |iliv>irian  the  s\ni|.lniiis  .it'ilif. 
iliscasc  n-srii.lilcd  I'l.w  ,l<>ciil„.,|  l.y.l.iniiT  as  lli..  swn|.|oiii.-  d'  lv|ili..i,| 
t'fVir. 

SnII  li-ss  rniivinrinu'  is  lli.-  wcll-kiiuwn  .■iiidcniic  at  the  sclio.il  nf  (  lai>- 
liain,  lilM-«i>c  ,-iir.|  liv  .Miir.'hiMiii.i  In  il,,.  Miniiu.r  nf  ls;i_',  nf  -ll  lin\s  in 
lliat  iiisliliiiinn.  ■_''•  w.tc  »i/.r.l  within  time  linui-*  w  i;li  ••  il>ni  \  |.|ini,|,"  w  itii 
vniiiitin'.',  .liarrliea.  ami  |ii-n-l  ratinn.  'I'hc  clisc-a>r  wa>  all  rilnit.-.j  in  the  fart 
that  tlic  lio\~  ha  I  uiln(--c  I  tlii.  re.i|icnin'.'  ^>\    a  Lirave  eln  ,■.!  t;.r  maiiv  v,:ii-s. 

the  -really  ih ii|>.,-.e  I  eniii  -ils  <if  w  liirji  ha  I  lieeii  1  hen  spr,  a.j  ii|k)|i  the  snij  iii 

tlle    llei-hhnl-h'.nl   nf  |he    |.huL'P,n.|   I   ,,fth  •   s    hn,!.         Tun  nf  the  alfeel   ■,{    l,ny,4 

'lit' '•  "  If  111!  T  :iii  illii'-s  nf  t,veiily-lhn-e  aihl  the  nlhei- afler  an  illnos  of 
tw  ■  ilv  five  hniirs.  'Ph..  antn|,sy  ilise|nse.|  aeiil-  su  •lliiii:  nf  I'ever's  |iatc|ie8 
a'l  I  ill  ■  siliiary  fnljieh's,  \  i.li  >li_'lit  nleerilinn  i,(  one  of  iIh-m.  .striietiires, 
tn.'.'i  her  with  eiilarL.'eineiit  nf  the  iiie- -ilerie  irlanJs.  The  i|neT.linii  at  once 
arises  ill  ennneetion  with  this  re|K)rt  :  Is  it  not  unn-iial  that  voiiiil',  previmislv 
healthy  i:iilivi,hials  ilie  fmni  ty|,li,,i  j  fever  williin  frnin  twentv-three  to 
twenty.fuM!  hours?  Can  the  aiiatniiiic  cmi  li.i.ns  fiiin.!  , level, ip  in  a  ease  i>\' 
tyiihnhl  fever  within  tli  •  time  iii.ntinnely  Is  the  sii.l  leii,  aliiinst  si, mil. 
taneniis,  illiic-s  «<i  the  |iii|,lls  sn  rL'eslive  of  typhnhl  fev.r';'  Are  xniniiinL', 
iliarrhea.  and  prnstratinn  evid  ■■le-s  „(  this  disease?  I),,  nnt,  rather,  all  of 
these  ein-iiiiist  i:ie  s  i:ilii-ate  siin|.l  ■  ialnxiealion  with  seuer-iMS.  which  in 
fact  was  at  lirst  -ii<|,;.eted  l.y  the  nhservers?  Siieli  eondilions  have  lieeil 
reen-ni/A' 1.  anil  it  is  known  from  tlit!  exiMM-iiiient.s  of  Ma-eiidie,  Leiiret  and 
Haimiiniid,  I'.arker,  and  others,  that  they  can  he  iiidnej  experinieiitally  in 
animals  l.y  the  inhalatinii  nf  put  rid  L'ases.  It  has  lieeii  learned  frnni'thc 
experiments  of  Slieh  '  that  aiiiinals  |)<ii>oiied  hy  the  intravenous  iiije<'lion  of 
putrid  suhstanees  exhihit  intesiinal  le,-ions  id'eiitieal  with  those  of  the  I. ovs 
at  Claphain,  namely,  intense  eatarrli  i^(  the  Inwer  pnriiniis  nf  the  intestine, 
especially  tlu"  ileinii,  with  acute  swidlini:  :iiid  even  exfiliatimi  of  Teyer'a 
liatehes  and  the  soliiai'v  f  illieles.  as  well  as  consecutive  liv|>erpla.sia  of  the 
related  in  'senteric  ;.'|an  Is. 


SIGNmCANCE  OF  EARTH  IN  THE  ETIOLOGY. 

Kai-tli  lias  played  as  iniiioi-taiit  a  roir  as  air  as  a  can-icr  and  dis-ciiii- 
nator  of  tlie  typhoid  |)(ii-,.n  in  ilie  views  of  physicians  and  in  the  litei^i- 
titi-e.  It  was  con-idi  ivd  as  tile  e-si'iitial  iindiiini  \\^r  tlie  stofitiir  np  and 
tlie  further  development  of  tlu'  imm-oii,  wlii(  h  was  helicv,,]  to  ori;:inato 
s|Miiitaneonsly  in  it  fn.in  putrid  .sni)st  iiiees,  or,  acconjinir  to  the  view  of 
Hildd  and  his  disciples,  to  he  deixisite-l  as  a  specific  coiitairiiini  and  tliefo 

•  L,n,.;'t,   IKJII,  v,.|.   xvi.  ;    M,,l.  ,i„:.,   v.l.  iv.  '  VlnuH;  .l„„„/,„.  tH.-,:t 


52  I  yili'iih  I  I  \  I  i: 

,,,    iiM.l.  1--    innltil.lir:,!!..,,.        Il    i-,l,:M;„|,il-n.of   ,;,rlir.-    .  |,i.lHni.  .|.  ..rir 

si,.„-    ,|,.,l    ll.i-    llp.n-lii.  uIm.'I.    U.I-   .vmI^,,!    llMMivtlrill^    Il ,,il.,n, 

.,  ,„,■., I  , AIM  ,„  nr,  -,  u.,-  ulili/r.l  :i-  :.  -.iin  1,,,-i-  lor  :ill  111,11.  r  ■  .■„,  lii- 
"i,„,-.  In  II,,-  u  IS  ».,v  ,s,,l,.n.,|  I.miI,  ll,.  -,,,,,11.-1  .,-  «.ll  M-  ll,. 
iumM  ,a|,  „-l\r  ,|„.l.i„l.-.  If  tM'l"'i'l  fNT""iinv.|  1,1  ;i  lioii-r,  .,|-..„ 
.,„  .,-,:,„•,,.,•  i„  ;i  I:,,-.,-  ,,n  ,,,  .„,lv  ll,.  n,i;.tr,l  -,ll.-..,l  u,,-  l:,kr,,  ii,l.. 
.■,„,-l,lrl;,l,..,,,  |„-,,\,.1..|  ll,:,l  .  ■■  .,,1 ;,  M,  i,,  1 1.  .  1  a,,'  U  -  n-l  <<\''  r.<\\sr.  ll  ,11 
;„|,|ill,,|,  |l,r  -U,,„,l.\  ,l,;,,:,.l.,-..f  ll,.'  ..,fll,  ■„■  ll,.'  |.l..Nl,,,i'V  ..(■  .llM,- 
!„  .|„  :,,,.!  -  u.  ,■-  «.,-  .  -l:,l.r,-l,-'l,  "I  il'  ill''  'I'll'  li'i'l  I'"  "  -"'■'""  ""'' 
,vr,,-..:,„,l  i„;.,„,,v:,  -l,..il.,"|-:i  l"ii'-:'i-  lil'i'-  l"'' v  i.  .i,-1n  .  all  .l..„!.l  uas 
,,  ,,i.,\.,|.  A-  ill.  iialm-.'  .  '■  ill-  ...1,1  il^iinii  «a-  ,,iikn..u  ,i,  al,(l  a-  ll,l- 
^\a-  ,■.„,-;.!.,.. 1  nil,.,'  a-  l:,—,,-  ll,a„  .•..,|.,,-r,,lai ,  ll  vv ,,-  |.. -IM.  M 
,,„iil„ii,.  ill,'  r..ii-tn,.ll ll,s|...tl„-.  -  ullli.Hil  i,l,„lia„r,.  Tl,.'  airma- 
il,,,, ,.-|„.,.ially  ...n-Ll.  ,.•!  a-  ll,.'  v.lii.L'  l"i-  ll"  |"'i-"ii  i"  'I'l'-ll"!'.  ^'H'' 
il  \sa~  ImH.  \.'.l  til  ,1  llll-  ,-.•:, p.,!  Il'..!ll  ll„  -..11  1,1  .•,,ll-r,,,lcMc'.'  <>(  a  -OI-1 
ufrva|...,-all..„,  aii.j  ua-  tli.  ,1  lin'lli.  ,'  ,11-1  rll.ul.'.l.       If  it   ua-    |,..-il.l,    H- 

>l„,u'  f,i,'tl„  r  ll,at   ill.'  -.11    ll  al    I"'  11  liii-ii'''l  ii|'  ill  l'"'  ii''iul,l"'il 'I-  ^'ii'l 

lliat  -l,.>,ll--  ImI'..,-.'  .'X.asail..,,-  l,ail  Im'.'M  l,,a.l.',  f.iiialal  1..I,-  -in-,  "i 
,lral„-l.l|..  -  lai.l,  ll,.'  Iia,,-f.  I'.,,.'.'  of  tl„'  i„f,'.'t.'.i  -r..„i„l-all'  t..  ll,.'  u..rk- 
III. '11  a,.. I  olli.  ,■-  -..  i,,..l  (1.  ,,i.i„-tral.'<i  a-  ii,  a,,  r\  |..  ill,,.  i,l. 

I), „■■„,■'    ll,.-    L','.at    tv|,l,..i.l    f.'V.'l-    i'|.l.l.'„ii''-    "f    IiM,„l.,iiv.    > iiiil-r- 

t,i,ial,'iv  iailii.'iiiial.  .a-lh  >ali>lu'.l  iiiilivi.i„al>  .•xplaiiifil  ll,''  ."'.'in-i.'ii.'f 
l„.s„i,.r  .l..".l,l  l.v  ll,,'  ta.1  ll.al  hir-.'  .•^^:lvali..l,^  u.,.1  l,„iMi„L'  ..|..'rMli.,„s 
W.TC  il,  |,r.,.',a-  al...„t  111.'  l,a,l...r.  That  lv|.li..i.l  sva.-  -hMnlail-.l  •'^rv  ll,.' 
citin'  .'ilv.  uiiili'  ll,.'  .■v.'avali..„>  ii,  <i„.'>iii.H  »<'n'  v„v.Uu>-A  U>  n  ,,arr..w 
s.-.'ii.,„   :„hI    ll.al  ll,.'   a.r!..i„i,iL'  Mr.  .is   Nvi-iv  l.v  ,,.,  i„.'aii.   .■>|..'.',all>   atl.'.'l.-.l. 

fnil.'ii  ti>  all',',  t  ill.'  |.,'.'' 'I'iv.'.l  ..|.,,ii..ii. 

Til,.  -,,ll-tli...,'v  I'.'.'.is.'.l  it-  -.'i.„tili.'  .l.'\. '1.11,11, '1,1  tlin.ll-li  the  u.'ll- 
k,i.,un  u..vk-  ..f  i;,il,l  a„.l  i'.'tl.'i,k..f'f.  ai„l  tl,.-.'  .l..miiiat.'.l  tl,.'  tl,.'..i'y 
of  il„',„'loi„  .,f  iN|,l,..l.i  f.'V.i-  until  Nv  ill, ill  ll"'  'ii"-l  ''■'■''i"  ''""'-•  ''"'"' 
on.ini.l-uat.'i-    tli.'i.i'v  ..f   Unlil  ami    iMl,'MU..f.'r  "a-   l,a-.'.l    ii|",m  tli.'  -la- 

,i-li,.:,l  ,,l,-,rs.'iti..ii  tliat  tl,.'  i I'l'lilv  ami  ni..i'talily  ,,f  ty  plioi.l   f.'V.r  in 

MiHil.'l,  1'.,-.'  ul,'ii  tl"'  -I'liilii.l-ual.r  ua-  at  a  l..w  l.'V.i.  vviiil,'  a  ruvr,- 
s,H,n.il„-  n'.i,i.'ti..n  ,..i-ii,'.i  « itii  a  I'i-.'  in  tli''  .:i-"iii,.'.-«at.T.  I'.ti.'U- 
k.,i;.|'  l,.r..'V.'.l  tiiat  1,.'  vva-  al,l.'  t-  -iv.'  a  .l.linit.'  .'Xlilanati,.,,  tu,'  iii.s 
uh-.rvati.M,-,    nani.'lv,    tl,at    tli,'    -|..'.'ili.'    Iyi'li"i'l     1  "i-""    'I'^l"]'-    ^li"' 

,n„l., -    n,aturali.,n    in    tl,,'   .i.'.'!-',-  lay..-   "f  tl'"   'arlli  -ati.i'at.'.l  wit  . 

snli-tan.'.'-  .'ai.al.l.'  of  uM'l.'iV'iiiiX  i.utf.fa.'tion.  Wh.n  tli"  ^^f'-H'l- 
vvat.r   i-   at  a  lii"li    l"v.'l    tl,i-   .lai.Lr.T.HH    lay.T  of  tl,''  -"H    i^ ''ov.'.'.'.!  l.v 

ti„'  lunii.T.  a, 1.1  i-  tin,-  .'Ht  ..tVf, tli.'  Mffa.'.'  .>f  tl,.'  .'ai'tli.  wl.il.'  vvli.'i. 

ti,..  ..p.nii.l-wat.v  o,'.'ni,i.'^  a  low  l.'V.l  tliis  .  N.'ln-i.,n  i-  w.mtinu.  I  ti 
tl,,'   I.,.-'  .v.'Mt.  Willi   tlie  ui.l  of  .^liccial   io.'al,   M'.iM.nal,   an.l   iK'fs.mal 


1^ 


iri'il.'ii;)  . 


63 


l1>Ml|itiMM-,  til )llt.l'jirim    llli^'lll    ||<>I    lie    |ill\  iHImI    t'lom    i-r:i|)l||;_r   tlnMlll'll 

till'  jiiiiiriil-iJir,  \\\i,\\  il  \\<.iili|  111-  |:iImii  ii|i  irilM  tin-  Imm|\  Ii\  iMli:ihili"ri, 
;ili<l   ill   ill..-.'  |ii.'i|l-|M,-,..|   wi.ijl.l  :ii-l  :i«  tlic  (A.ihiiit  ..I' ill.'  ili-i:i-.'. 

I  III      llli..fS    ..I'     I'll!.  Ilk.. I'.'.      .II-i.II^mI     :illi\r     u|l|Mi«il|.ill     -111.11     Ml'til      il- 

aiiiiiiiin.  I  iiiiiil.  .nil!   llii-  ill  |>:irl  \\;i-  lia-ii|  ii| llir  .siKi-icinc-.  in  i.tlu  r 

rilic-  will  IT    lllr    ri-r  allil    lllr    Ulli    nl'    till-   Ufi  iinil  1  -  w  :ltl  T   lliirc    II. .    fllati..ll    |.i 

vaii:iM..ii-  ill  till'  |.ir\:ili  HIT  ..|'  l\|ili..ii|  ti\  ir.  aii.j  in  |iail  wa-  iliiTrlid 
.aL'aiii-l  llir  llii..iTli(al  n.inlii-i.ni-  ..I'  lliat  ili-tiii:,'iii-lii'<l  I  \  i.'ii'iii-l. 
. Villi. MLT    llii'    raili.-l    alla.k~    liia\     hr    iiiiiit  iuiiiij    IJir    |ia|ii|-     ut'     l,irl>rf- 

liiii-liT  '  ami    l!ii  iiinr,'  uliirli  aiTiA.ii   |i.-ila\    Iil-    i.t'  .-i-ilii-al  iilili/.a- 

li"ii  I.I  all  lli;il  «a-  kii.i'Mial  lllr  liiiir.  'I'lii-r  iiiiiiaii'nl  tlir  -laliilit'.' 
Ill  I'.iiriiL.irrr'-  iliii.rv,  \liiili,  ill  ilic  lii^lii  III'  |in-i.|it  kiiuw  ImI^i-,  lia> 
no  I..IIJI!-  till'  -iirniliiaiiiT  that  \\a>  attaiiiifl  tn  it  liy  it-  aiillinr  ami  lii> 
|>ii|iil-.  \\  illi  iT'.rinl  III  till-  -I  iti-liral  ..li-(  rvalii.ii-,  tln-f  aiT,  it  i-  iriir. 
appliralili'  I.,  ill.-  i-itv  III'  Miiiiii-li  ;  lini  it  Im-  li.-i-n  ilriiiuii-tiat.il  that 
llii-y  aiT  ii.it  a|>|ili.-alili-  l..  a  iinmlii-r  uf  .illi.-f  riiii--,  ami  lli.-x  aiT  n-r- 
laiiilx     III. I    -ii-i-i jiiilili-    1. 1'  u,-ii.-ral    a|i|ilii-aliiin. 

\\  illi  n-lali.iii  III  till-  li.-lias  i.'i-  .iC  tin-  t\  |iliiiiil  |Mii-iiii  in  tin-  -uil.  aci-nnl- 
iiii;-  I.,  llic  \ii-w  III'  rctti-nkiifir,  tlu'  kimu  liil^r,.  .-.miinniil  i-\|K-riinciitall\- 
lliat  till-  liarilli  lit'  Kli.Ttli  an-  i-a|ialili-  uf  iTl.iuiiiiLf  llii-ir  \italil\  in  tin- 
carlli  liir  a  Imii:  tinii; — l)i'lt(-r  in  |Mir.iii~  tliaii  in  riirk\  ur  utlici'w  i-c  iniiH'r- 
vioii-   -..il  —  iiiiulit     he    ciniilia-i/i-il.      (m-.m-Iui-  ami    1  >(i-liaiii|>-   <ili-i-r\  t-d 

iIhiii    to    |ii  r-i-I    for   livu   ami   a    half  ih-   at    the   ilcplh  of    ',   imti-r. 

'I  hi-  ii-i-lamc  i-  |iiiilial>l\  not  j.Miatl\  iliiniiii-lii-il  Kv  i-olil  mikI  ilrvm-s 
l-ri'  |(.  -'l-i).  -II  that  till-  |)oi-iin  may  nnili-r  favofaMc  i-iiTimi-taiiccs  -ni- 
vivi-   ill    thr   raith    l)..th    ilii-oii;rli    the   lold  a-  will  a-  the  luatcd   si-a-on. 

I  I'l'   I ditioii-   ai-c   ililli'iTnt,  howi'Vir,  with    iTirard    to    the    h\  [Kithctic 

iiiaturalioi,  and  |)ro|ia^r:,tioii  of  tin-  liai-illi  in  tin-  earth.  Tlic  fir<t,  in 
arcordaiKT  with  i-xi-tinj:  know  Icdixc,  i-  not  at  ;ill  |i|-ol)al)lf  or  i-^  -o  in 
Imt  liinitid  d.-j.'-r'r.  Any  con-idcralili-  iiinlti|iliiation  >>{'  the  hacilli  in 
till'  i-arlli  or  any  inrna-c  in  tluir  viruhniT  i-  wlmllv  iimlrinoii»tf;iti'd. 
In  any  event,  tlie-e  tliiiiir-  do  not  i.ceiir,  as  a  rule.  /.l-o.  detinite  local 
or  seji-idiial  condition-;  cxertintj  a  favoralilc  inrimnci-  in  thi-  connection 
have  not  hceii  clearly  dcinon^tnited. 

Kveii  it'  the  other  ii|iiiiioiis  ut'  I'etteiikoi'er  wen-  lietter  sn|)|Hirte<l,  his 
hypothe-is  that  the  poj-on  tlnds  its  way  into  the  air  from  the  earth  and 
is  disscminatiMl  in  .his  way  would  he  ino-t  dillieiilt  of  deinonstnition. 
This   Would   he  coneeivalile  of  a   jr;iseoiis   poison,      'i'lie  known  corpus- 

'  S.-..  I'.-ti,-iik..f.-r.   r.l>,r,r,,.  l,„it  ;„,  11,1,1,  ,n,.l(i,;<t,.il„,t.  Unuir.-rluvc-ii;,  18T:i. 
■'  (1,H.   Ah/iiiii,/l,i,i;lf-ii  II.   Zirm.i.wil'.l  lliu,illi,i,-h.    1    .VuH.,    H.l.   i. 
•  \'uU:innnn'n  Sainuilumi  ktin.  Vurfr.,  ISTJi. 


ryi'iiiiih  Fi:vi:i: 


,.,ll;ll-  .we    111'  the  nillt:iL;illlii    i-.   Imw  iv.r,  directly  (ii.|)(.-r<l    t"    -nrli    :i 

vicu.  iiil\     In  (Acrlilinii;!!   ill-tancc-,   alt;irlir.l   111   ]);irli.4<-    III    ilu.-t    arl- 

iii.r  a-  iii-iiT-.  niiild  il  ii-aiii  accv—  In  tlir  limly  dinclly  tVniii  till- tarlli 
and  i-aii-r  inHclii.n.  'I'liu-.  it  i-  I'lincrivalilr  thai  in  llic  cuir-r  <A'  r\ca- 
vati'iii-  and  dllur  (i|)(  ratinn^  iii"in  inHctrd  -nil.  Hcrin-cnitainin^  dn-t 
iniuht  ^ain  dircrt  cntraiKM'  into  tlif  inmitli  and  thcin'c  iiitu  tlir  diiir-livi 
tract  nC  tlic  wiirUnicn  tliii--  cii-a-vd  anil  caii-c  inlcctiuii.  and  that  the 
individual-  lhn~  inlcctid  n\ii:!it  caii-c  tiifllicr  .li^-cniinatiun  uf  the  di- 
ca-c.  Kvcn  in  thc-c  ca-c-,  huwi  vci-,  the  |iriil)aliilily  nt' inii clinn  ihrniiLih 
the  -oiled  hand-.  cl(.thin,L^  ailicle-  of  liiod,  etc.,  i-  ^lill  j^ivatei-  than 
that    thfonuh    inhalatimi. 

The  iifiiici|ial  mode  ot'  di— einiiiation  of  typhoid  fever  from  -nh-oil 
cuiitaiiiini:  tv|)hoid-l)acilli  will  alway-  remain  that  thriint;h  water,  a 
medium  to  which  tln'  lieliever-  in  the  locali/.itioii-theory  allached  I'ar 
loo  little  im|iiirtancc  frmn  the  ont-ei.  I'roin  ai  that  i-  a-  yet  known, 
water  i>  liv  fir  ln-t  ada|ited  to  take  iijt  the  iia<'illii-  from  the  earth  and 
to  elVeet  it-  further  di— eininatioii.  'I"he  t;erm  may  thus  find  it-  way 
into  tlowiii!.'-  wat<r,  or  under  favoralile  condition-  i;ain  entrance  from  the 
Mil>-oil-wat.r  into  well-,  or  !«■  wa-lwd  out  of  the  niiper  layer-  of  the 
earth   l)v    iiun   and    melted    snow. 


It        ^1 


INFECTION    AND    DISSEMINATION    THROUGH    HOUSE- 
HOLD ARTICLES. 

IJcference-  to  thi^  -iilijecl  have  already  heeii  made.'  Ill  view  of  the 
|)ractical  imiiorlance  thereof,  it  -eem-  de-iralile,  houever,  to  return  to 
it    at    irreater    leni;tli.       rndoiilitedly,    the    typhoid    poi-on    may    remain 

attachid  in  an  a.'liv  -tat.-  for  a  i-ideral.le  leii-rtli  of  time  to  elothinir. 

lineii,  l.eddin;_',  and  various  lioii-ehold  article-.  I'nder  -iicli  .irciim- 
-taiiee-  th<-e  article-  are  irciierally  coutamiiiat<'d  directly  ov  iiidir.rlly 
throuirh  tlw  dried  deiection-  from  tvphoid  patients.  Natiirallv.  under 
thi-e Cirenm-tanee-  the  fiinilv  of  the  i>atieut.  the  attendants,  lamidre-cs. 

and  other  i.er-on-  w  ho-( upatioii    re.|uire-  that  they  .■omc   in   e,iuta<-l 

with  t''e  article-  in  .pic-tiou  are  mo-t  e\|io-ed  to  danp'i-.  Inteetion  is. 
however.  frei|uent!v  lirou-lit  ahont  indirectly  throuudi  healll.y  iiiter- 
m.'diaric-.  who  r< main  well,  ar.d  who  may  convey  the  poi>on  atlaelie.i 
accidentally  at  the  lied-ide  to  their  .■lothinir  or  their  hand-  ;  and  without 
donht  a  nniuher  of  ca-.-  of  ol.-.aire  etioloiry  are  altrihutai.lc  to  -neh 
.i.Murrcnee-.      Naturally.   ]ihy-ician-    -hoiild    alway-   l.cir   in    min<l   that 

liu.illu-  uiiiliT  vur\iiit;  i/iiinlili"ii-  "f  ili-irratinii. 


irnoi.'xiy. 


r)5 


tlifV  niiiv  tlicinsclvcs  Iir  tlir  iiicMii--  III'  ciinvi  vinir  typlioid  fcvfr,  in  flic 
>am('  UMV  ;i.->  MHiic  I'llici-  iiir(cliiiii>  ili>c;i>c~,  |p\  liiilliic  tu  iili-ri\c 
Mili(|ii:iic  iH'ic'iiitiiiii-.  'I'licrc  is  nil  ilmilit  tiiat  int'iiiiuii  ni:iy  t;ikc>  phicc 
;it  :i  (li-I;iiiic  liv  tiic  trMn~nii~-i<in  in   int'crtcd  nt(ii~ii-. 

A  nmiiliir  nt'  vcars  ai'ci  liic  tollowint:  iiislriictivr  ixpcriciico  Dccurreil  to 
MIC  :  A  viiiini:  incrcluuil  livinir  in  niiilillc  <  icriiiany,  ulio  w.-i^*  accusloincil  to 
M'lul  a  |iiinii>ii  ot'iiis  cloliiiiiLr  ami  linen  to  liis  home  in  IIainliiir<r  lo  lie  lann- 
ilcreil,  conliniicii  this  practice  when  attacked  with  "L'astric  lever."  Ten  and 
twelve  davs  respeclivelv  alter  the  si>ler  of  the  patient  and  a  servant  had 
wa-hed  the  linen,  they  lieraine  ill.  the  one  with  a  mild,  the  other  with  a 
.severe  attack  ot' typhoid  liver.  'I'hal  the  lirother  had  also  sntiered  from  the 
same  disease  was  nnfortnnately  demonstrated  liv  iintopsy,  death  occnrrinfr 
from  copious  intestinal  hemorrhaire  in  ihe  co  .r.se  of  an  apparently  inihl 
attack.  While  the  mode  of  infection  jnst  mentioned  is  liy  mi  means  rare 
for  the  acute  exanthemata,  especially  variola  and  typhus  fever,  and  in  the 
acnie  infections  diseases  most  cjoselv  allied  to  tiietn,  and  nuist  lie  taken  into 
eonsideraliiiii  in  cases  ot'  obscure  ori;jiii,  little  or  no  reference  is  made  to  it 
in  the  literature  or  in  practice  in  loniiection  with  tvphoid  t'ever.  The  samu 
thitiL'  happened  with  re;.'ard  to  this  as  occurred  with  a  nnmlier  of  other  cir- 
cumstances of  etioloiric  im|Kirtancr.  They  were  all  ncirlecleil  or  i;:nored  for 
a  loiii;  time  from  the  cnstotn  of  looking;  at  .dl  thitiL's  from  the  point  of  view 
of  the   iivlhotrenic   or   the   sulisoil-theorv. 


FACTORS    THAT    FAVOR  INFECTION  AND  DISSEMINA- 
TION OF  THE  DISEASE. 

Ha\iiitr  tlms  t'af  ucciipicil  iiMrs<'lv('s  witii  the  diiect  causes  of  typhoid 
fever — that  is,  witii  the  pccniiarilies  uf  it>  specific  ciinta<rinni,  e>|>ceially 
its  vital  relation-,  the  variiin>  pussjliilities  of  its  imilfi|ilieati(iii,  dis- 
scininat'nii,  .iiid  iiiva-imi  in  flic  human  ImhIv — we  shall  now  take  up  tlu^ 
ciintriliiifnrv  tiicfur-.  namely,  flio>c  that  are  of  impmlaiice  for  flic  recep- 
tion of  file  poison  into  the  liody,  tiir  its  further  ilcvelnpineiit  therein,  mid 
liir  its  jiatliiiirctiic  activity. 

Individual  liudilv  cdiitlifinns  and  acipiired  ccinditions  tavorinir  the 
(levelupmcnt  of  the  (li>ea>e  arc  especiallv  to  lie  taken  into  ciinsideratioii 
in  fills  cdniu'efion.  I'erhaps  with  fnrther  advances  in  kii(iwle<lp'  wc; 
shall  learn  to  divide  fiicse  inHiieiices  into  fhnse  that  lower  the  resist- 
ance ot'  the  orjraiiism  to  the  haeilli  and  tlidse  that  directly  ia\(ir  their 
\  italitv  and  mi  '  iplicatinn.  .\t  the  present  time  Init  little  is  known 
concern iiijr  these  mattci-s.  We  have  not  advanced  tiir  heymiil  tlii' 
theoretic   jrnidcs   to   the    liins   fur   future   invcstijrafion. 

A  ^eciiiid  impnrtani  irronp  of  cuiitrilnilury  facttirs  consists  in  the 
I  nditiims  exislint^  outside  id'  the  Ixidv— locality,  climaf«',  season  of 
the  vear,  etc.  Altiiiinj:-li  these  also  to  a  certain  dejjree  act  n|Hin 
the    individual,    their    principal    sijrniticance,    htiwever,    resides    in    the 


56 


ryrii'iii)  ikvf.h 


iiitliicnrc  tliMt  tlu'V  cNift  ii])(iii  tlif  licliMvicr  c  ,,,«■  ]►  -  .11  <lc))«>sitc<l 
ami   pnxrvrd   .nitride  of  tiic  1«m1\  ,  upon  it>  per.-'  '   1:1^    ,1-  liirtlirr 

(Icvclopiiicii  Miicli  tliMt  has  iMtn  said  with  fVLrin)  t..  the  tciiacilv 
of  ilic  |i(ii-nn  is  appliraiMc  in  this  ((imici'tiuii.  a  the  wiiolc,  <>iir 
in-fsciit  kno\vh'<h_n.  ill  tiii-  ti.j.l  i-  l.ii^.d  ratlicr  u|h,i-  . mi.iiii  than 
tlu'orctic,   i-]>fciall_v   cxiKiinuiital,    irrdund-. 

FACTORS  RELATING  TO  THE  INDIVIDUAL. 
Age  and  Sex. — Tiif  \-n-\iv  nninlur  nl'  statistical  data  with   refer- 
ence to  these  -uhii'cts,  iiowever  exact  they  may  apiiear.  iiiii-t  lie  received 
witli  ;rriat  cantion.      Many  are  ol>\  ioiisly  not  at  all    in   acconlaiice  with 
the    facts,  while   others   a^n-ee   only    on    jrcneral    line-.      .Most    nii!_dit    he 
e.\|iceted  fnini  cxtcn-ive  olllcial  statistical  stateinciits,  covcriiifr  m11  of  the 
inlialiitanls  of  a  country,  hotli  the  well   and   the  sick,      rniortnnatcly, 
the-c  -utfcr  from  variation   in   the   rcliahility  of  the  diaj^nosis  and  front 
the  deticieiicv  in  anatonii<'  data.      In  lio-pitals,  on  tiie  other  hand,  where 
these  con<litinns  are  tlie  most  favonihle,  other  iiictor-  throw  doiiht    iiiion 
the  statistical  iv-nlts.      Thu-.  there  is  often  the  sinallness  of  the  nninher 
of  cases,  and    almost   everywhere   the  class  of  patients   admitted  to  the 
hospitals  d(«s  not  represent  the  avcnijxc  poimlation  of  a  coinmnnity.  and 
thercfi-e   the   real   averajre   morhidity   is   no'    repre-cntcd.      in  this  con- 
nection it    is   e>peci:lllv  to  he  taken    into  coiisidei-ation  t'    t  chihlreii  and 
married  |iersons  are  for  ohvions  reasons  less  commonly  sent  to  ho-pitals 
than  imniarric<l  adults,  mchanic-,  laliorcrs,  servant-,  visiting'  straiifrors, 
et<'.      Of  the   married,  experience   has   al-o  shown   that    everywhere  tlie 
women   ^-o   to   the   ho^jiitals   less   commonly  and   «ief<r   entrance   ]on^r,.r 
than  the   men.      In    wcidiinir   the  sijriiiticanee  of  statistical   data   these 
circumstances   -lioulii    receive   ajipropriate   con-ideratioii. 

As  to  the  iiitlneiice  of  RgC,  there  is  no  doiilit  that  youth  e-iiecially 
predisposes  to  tyjihoid  fever,  and  the  period  of  life  hetween  the  tifteeiitli 
and  the  tliirty-tifth  year  is  iiy  far  tlu'  nio-t  comiiKMily  att.icked.  In 
mv  .'xperieiKT  fully  four-fifths  of  all  <".ises  occur  at  this  period,  an<l  in 
this  comiectioii  it  should  he  not  d  further  that  more  than  half  (ahout  of! 
p<T  cent.)  occur  hetwc'!;  the  tift.'cuth  and  the  twenty-lifth  year.  Hetween 
the  thirtieth  and  thirty-tifth  years  the  nunilur  of  cases  diminishes  some- 
what, to  fall  coM-iderahly  lictwecii  the  thirty-tifth  and  the  fortieth  year. 
After  the  tiftieth  ve;ir  the  morhidity  can  he  exiiresscd  in  fra.'lious  o(  1 
percent.  lu  old  ai:c  the  di-ease  can  he  con-idcred  as  rare.  lakewise 
in  earlv  ehildho.Hl  n|)  to  the  first  year  of  life  typhoid  fcvi  r  is  mre,  as  is 
known  also  of  most  other  acute  infectious  di-eases.  From  the  first  to 
tile  fifth  year  a  gradual   inerea.se  takes   place.      From   the   tifrh  to  the 


"if 


KTioijjii  y 


67 


tirt<-<'iitli  y(-,ir  llic  |)r(><li^]X)siti<>ii  hccomcs  still  {rrcatcr,  so  that  (liiriiijr 
this  |)cri(«l  more  arc  afUctcd  tiian  hctwcfii  the  ihirty-tif'th  and  Corticth 
vcars. 


Tlif  fiillowiiiir  ti^rurcs,  liaseil   U|)()ii  ohservatioiis  made  in   the   liospitain  of 
Haiiihur;:  '  and  i^M|isi(',    may  st-rvf  to  illuslratf  what  lias  liet-n  said: 

(  '((«.<  ,,/'   Ti/jili'^iil    Frn  I-   ill    llii-    Hiiinlxirij    (Irnentl  Jloyilln/,    JSSd'-S'/. 

IW*"''.  18*17. 


!i 


10  .   .    . 

11  .   .    , 

12 

l:l 

14 

l-")-'J(l  ... 
L'l -•.':.  ,  .  . 
2ii-:;(l  .... 
:!l-:!5  .  .  . 
:'.i;-4o  .  .  . 
41-4.)  ... 
4<;^')t)     ... 

•"iI-Vj       ... 

rui-tio  .  .  . 
lii-ii:. .  . 
<iil-7(»      .    .    , 
.■\i:>'  tint      I 

.-pccirifil.     I 
T..t,-.l  .   .    . 


4 
4 
4 

;• 
.{ 
10 

111 
111 
l-J 

IM 
IS 


|K(» 

7h 
■-'7 
21 

t! 

1 


'.i.il 


b'limlf 


M 

ICii 

114 

•  Hi 

:!4 


514 


]:! 

l:) 

I'.i 
24 
2H 
17 


40S 

:ii:'.i 

24i; 

112 

.'lO 

2il 

11 


1 
0 

l:', 
144.-. 


IVn-i'iil- 

0.2 
I '.  2 

o.i; 

O.'.l 
O.  .'i 
O.'.l 

o.i; 
1  :; 
1.7 
l.'.i 
1.2 
l.'.i 


17.0 

7.S 

Is 
O.K 
0.1 

0.2 

O.I 
0.0 

O.'.l 
HH1.0 


" 

Ki'iiiali-, 

Tcital. 

age. 

1 

•  > 

4 
i; 

0.18 
0.27 

7 

1) 

" 

(i.:)l 

:i 

2 

') 

0.22 

II 

1) 
11 

i; 

0.27 
0.40 

:i 

!» 

IH 

O.KO 

HI 

11 

1:! 

22 

2.'> 

21 

412 

41.S 

24:1 

114 

.M 

l:i 
4 
4 
II 
1 


I.-. 
II 
21 
l!l 
11 
2H() 

2o:> 
107 
4:; 

2ii 

IS 

•> 


4:i 
44 

;>*' 
i;ii2 
1128 

.■{r.ii 
1.'.7 


II 

II 


'  I  12 

I. Ill 
0.M8 
I. '.12 

i.itrt 

1.48 

:io,S8 
27.  W) 
l.',.s;» 
7(11 
:i.44 
2.4:> 
0.117 
0  4!» 
0.22 
O.IH) 
0.13 


1437 


804     !    2241         KHI.OO 


'  II.  Srljiitz,  ■■  Hiitrau'  zur  StiUi>tik  dcs  .Vli(l.iiniiiul-t\  pliii-,  .lfi/,rh.  ./.  Hainhnnift 
St,i,il^-I\raiil,(ii,iii.<ta!tr„.   IH8'.',   I  .laliri;. 

'  ('.   HiTi;..   hiii'iri.   DisH..   Lcipsic,   IWI:!. 

lii'tli  iif"  tli.si'  >tiiilics  wen'  iriiidi'  iiiuliT  my  din'rlion.  Tlu'  (li^sprtiitinTi  of  Hits 
I'ollow.i  tlir  w.irk  i.f  Scliutz  with  rft'cri'iiif  tii  the  stati-ticiil  iiui'sticins  ccn.sidiT-il  and 
till'    Hrrniii;ciriiMit   nC  tlii.   inalcriul.      From    the  year   IHHII   the   re.-ults  are   based   iipcm 

iMi'orimiliiin  (il.taiiied  l> aii>\viMs   In  a  yerie-  iil' miestinii.-  that  I  have  introduced  into 

the  Leipnic  hospital-  in  the  suiiie  form  us  UM-d  in  the  Hamburg  hospitals. 


58  ryi'iio.i)  fkvf.h 


w    iiiialv>is    i>t'    Itl-ll   ciisis   lit'   tviilidid    tivcr    m 


tlic    .laciilissiiii 


11    o- 


l,i"i|isic   hctwcfii    l^MI   ami    l.H'.t:!  .lixliwil   llic   (nlli)\viii;_'   ti;riirrs  : 

A.. I,      i>-.i    i»i     is^j,    1-v;    i^^i    i^^'.    i^~'    '^"■-    ''^^'"    ''^'~''    '*'■"'    '■"'■"     '^'''-'    ""'■'■'■ 


I 


II 


1 


., 

II 

II 

1 1 

1 1 

II 

II 

o 

n 

II 

II 

II 

II 

II 

II 

II 

1 1 

i 

II 

•J 

II 

o 

0 

II 

II 

'J 

1 

1 

1 

11 

■_' 

II 

i  1 

1 

;; 

1 

II 

I 

II 

'J 

o 

II 

II 

i; 

;. 

It 

■J 

:. 

■J 

'J 

1 

■J 

1 

4 

(1 

10   14 

',1 

ill 

7 

;, 

r, 

1 

s 

1 

III 

■"• 

i\ 

li 

4 

l."i-  I'.i 

j;, 

:;-j 

11 

■_*"i 

L'S 

;:o 

■Jl 

-'■'• 

IT 

:*\ 

:'.i; 

;'.*J 

IS 

•'i 

■JO  -.'4 

■js 

.Ml 

'S-', 

:;i 

:;.", 

■  VS 

»ii 

I'.I 

L'l 

*■-'_' 

:;t 

"';> 

-'• 

•'■ 

j;, 

; ; ,  J 

li. 

'J'l 

L'.; 

■_':; 

It 

"J-I 

■J.I 

;;ii 

■Jlj 

|.s 

1'*-! 

4 

:;o  :;i 

h 

ii; 

s 

IS 

111 

> 

1-J 

7 

1.-. 

l.'l 

■JO 

7 

4 

.-, 

i:; 

i; 

M 

1 1 

~ 

1    1 

.'. 

.'i 

11 

111 

7) 

'■'• 

(1 

4(»  44 

i; 

■t 

■J 

1 

1 

.'i 

1 

■  i 

0 

•i 

■'■ 

i; 

'■'• 

■  ) 

4'.  r.i 

II 

r, 

1 

:; 

1 

- 

II 

I 

1 

4 

1 

1 

•1 

II 

.'.n  :,l 

1 

1) 

_^ 

I 

II 

■J 

*J 

1 

L 

.'i.V  .'.'.I 

1 

11 

11 

1 

1 

- 

- 

1 

1 

1  - 

n 

II 

1 

II 

i;ii-i;'.i 

II 

1 

11 

(1 

II 

II 

I 

L' 

II 

- 

1 

1 

- 

II 

7n  Ml 

(1 

1 

II 

II 

II 

II 

It 

- 

II 

'■'• 

0 

II 

0 

(1 

T..U.1.  ir;    i: 


I-Jl      l:;s      l-jo     Ijii      in:', 


l'i4     l.!7     ir 


Arniiiirfil    arronliiiir  to  a^ri'.s.  tlicsf   t'oiirtfcu   \i'iu>  >himcil  tlif  tiillii\viii<; 
ri'laliiin<  : 


.\i.E. 

I'aus. 

I'll  icnlUK'-  " 
all  iii.M-s 

o.m 

Xuy.. 

1 

f! 

:!0-:;»           .    . 

'i 

•» 

O.l:! 

:l.i-:l'.i       .    .    , 

;! 

/ 

(144 

41144            .    . 

4 

11) 

III'.:; 

|."i-4'.i       .    .    . 

.■V-Ii    .... 

4i! 

J.  so 

•  iil-.i'.i  .... 

10-11       ,     .     . 

8i; 

.-.to 

i;o  li'.i      .   .   . 

1.-.  r.i    ... 

;).-i!i 

•J-J. 40 

711  si;      .    .    . 

L'll--JI       .     ,     . 

4:i4 

•J7.IK' 

T.itil 

'_'.'p  j'.i 

■w:, 

I'.l-.'iO 

JIM'S. 

rtTcriiiJu.'f 

nil   Dl'l'S. 

.f 

n;: 

1(1.40 

KM! 

r>.iil 

41 

li.'iO 

'-'!• 

ISO 

20 

l.L'.-i 

10 

(i.i;:i 

5 

(i.:!-J 

Ull-'il 


III  view  of  till'  hir-r   iiunilxr  nf  cliililrcii   ■  4.'(1  i  tr.'atfil  at  Ilanilmrir  in 
is.Hi;  s7.    it    niav   lir   |iriilitalili'   to  rmisiilcr   tlie.-^i-  in   lalmlar  funn  ; 


Nuiill'rr. 


ii; 

is 

i;; 


r,r.'.  MlNL-l- 

.r 

.■lliMrni  al 

tai  k.'.l. 

l.i.d 

1    s.-, 

,;  711 

4  -.'o 

:'.  :'.o 

10 

II 
1-J 

i;; 

14 


r'Tcrnlnm-  ttf 

Nuliil"T. 

I'lnliiri'ii  al- 

la.ki'il 

44 

II. '.HI 

M) 

11 . 1  "1 

■lO 

ll.:{() 

r.o 

lU.liO 

71 

\:,.:*) 

(■4 

I4.:i0 

4:.l 

«       .  T,  '"I"  T.tal      .     . 

'I'lir  lahlr  >linu>.  as  lias  Ihtii  imliratcil,  that  ty|ilioiil  t'fvcr  is  iml  t'rci|iicnt  in 
cliililliniiil  nntil  alioiit  t!ic  littli  y.-ar.  wlirii  tlii'  triM|mMicy  ^'railiially  incrfascs 
until  the  ninth  year,  then  to  rrai'h  its  li.iirlit  after  the  tfiitli  year.  A  coni- 
jiarisoTi  with  the  slatriiifiils  nt'  i-ci-ii^-ni/.i'il  aiitlmritifs,  as.  for  instani'c.  Muv- 
chisoii,'  Ficiilcr,'  anil  <  Iriissinircr.Mi.-closis  ai:rcciiicnt  witli  tlic  li.iriirfS  ;.'iven. 

1    /),,/.;/. /,,,„/,, I    Kranl.l,.  it.  ,1.   (JiTlllllll   I.V   /.lll/rr.    liniu  ll-rll  «  .ii:. 

■'  .(,-.■/,.  f-    //..//,,   isn-j. 

»   Vc,:-h.,„   .  Il„n,lh,„l,  .In-  spr.-uUni  rnllLuluiji,,   1W4,  1'  Allll.,    H(i.  ii. 


KTIOI.OCY. 


oO 


Thus.  52  |KT  I'ciit.  of  Miirctiison'-i  |.iiticnl-  were  l)ct\vccii  fifteen  and  tweiitv- 
(ive  years  old,  |-"iedler'  re|)orts  lliat  '>>*..>*■  |ht  ceiil.  of  his  |iatieiits  were 
lielwceii  the  twentieth  iiid  liie  tiiirtietii  year  of  aw,  while  'AA  per  icnt.  were 
aJHive  for:y  and  only  (t.7  ]mt  cent,  were  more  than  tiflv.  The  stali.-ties  of 
(iriesiiiirer  also.  ileMloiir  „ith  more  than  .')!()  eases Oliservecl  in  Zurich 
hetween  l<H(i()  and  Istili,  inclnde  L'd.l  per  <ent.  iietueen  the  tenth  and  the 
nineteenth  year,  4t).)i  per  cent.  Iielweeii  the  twentielii  and  twcntv-ninlii 
year,  and  l)i..><  ]K'r  cent,  from  tlie  thirtieth  to  tiie  fortielh  vear.  The"  .-tatis- 
tics  of  l,iehermcister  •'  are  particularly  instructive.  a>  this  oiiscrver  carcfullv 

leavored   to  avoid   the  statistical   error-   allenihnil   upon    the   inclusion  of 

lios|iital-palieuti! : 


Age. 


Krnni  ID  !■■  L'o  vc-ir- 

■■  I'l  ■■  :!o  ■■ 

•  :;i  ■■  40  ■■ 

■•  41  •■  :.(i  ■■ 

■'  .-,1  •■  i;o  ■■ 

■•  <;|  ■■  70  •■ 

.\li..vi'  70  M;irs  .    . 


Nuinl'iT  y'i  I'crc-rnlllL'i*  o| 

la-.  >  Ml  ilii'  i.iCii  iiinii- 

lyi.li.ij.l  r.\, T. 


.'il'.-! 
!»H7 
274 

MM 

:iO 

II 

I 


i'miiitiiL't'  "I'      I'n  ili-|ii,'.iii.,n  iis 
till-  )ii:e  in  Iht-       cuijipjiiril  wilh 

tnlal   [.npllla-         tllf  li\'   la;.-.-   r.-pff- 


ti.lll. 

s.-im-.l  l.y  1 

:i 

VI 

l.ti 

.s 

■j;i 

2.0 

i; 

-■» 

0.7 

>) 

111 

0.3 

•i 

10 

0.2 

O.fi 

fi 

0.1 

().(« 

3 

0.02 

The  freipieucy  of  typhoid  fever  at  various  atres  iias  heen  estimated  from 
the  rnortality-tahles  in  a  nundier  of  works  characterized  liy  the  larfrene.ss  of 
the  tii.Mires.  These  collections  fail  to  v'ive  a  representation  of  the  actual  .state 
of  affairs,  as  the  mortality  is  variahle  at  different  )ieriods  of  life,  and  .some 
periods,  a.s.  fijr  ii}.stance,  old  aw,  e.vhiliit  unusually  hii'li  fiL'ures.  I.ieli.'r- 
ineister  therefore  rei)roiluces  the  mortality-statistics  Of  llairenliaeh'  with  the 
same  <pialitication.  The  followintr  tahulation  hy  Mrouardel  '  of  Iti.o:!!) 
cases   is  most   instructive  in   this  counection  : 

Ih(ifli.-<  fi;,iii   'I'tiplioi,!  F,' If,- ill  I'll  i-l.^f row   ISSdfo  ISS.'/  ro,i.^lilrrn)  iwi-oiiliiiii 


to  Aij 


''P '"  1  .vi"" :iti  From  -'in  1. 1  ."!-'.  v(-iirs 

Fn.iii  1  t.i  -•.years 1041  ■•  :!.",  --    )o  '  .. 

■      •'>  ■     10     ■      12(!.-,  '■  40  ..  4,-,  .. 

■■    1"   ■  i-'i  ■•     in8t;  -•  4,-,  ■-  ,-,(1  .. 

•      '■■'  ■■  i;<>   ■' LVMil  .\l„.v,-  .-,(1  viars  .    .    . 

'■L'O  -■:;.',  "     :j><.|,; 

'•    2-'i  •■  :!0  •■      v;(Wl 


771 
4 --,7 


lti,(l:ii; 


On  comparinfr  this  with  the  i)recedinj:  tahle.  it  will  be  seen  that  the 
marked  ditl'erences  in  morhidity  are  ohiiterated  ;  thus,  for  instance,  the 
fiirures  for  children  I.etween  the  first  ami  the  tenth  vear  equal  those  for 
IKT-sons  hetween  the  tenth  and  the  fifteenth  year:  and"  there  is  little  differ- 
ence hetween  the  aws  from  fifteen  to  thirty";  while  the  fiL'ures  for  old  ajre 
are  comparatively  hiirli. 

Sex  c;iuses,  ai>i)areiitly,  little  difl'crence  with  rcirai-d  1m  infection 
with    typhuid    fe\  cr.      On    the   whole,   amoiijr  adults   men    are   attacked 

'  ' ■  '■''  '  /'V/»,s'.s,-)i  .s  1 1, III. /III,,-/,.  :!  .\iill      |{,1.  ii..  II. -ft  1.  S,   rj4, 

'  ./„/,, -h.   ,1     huKli  r/,,-,ll;..   None  Keli.'.-.    1,H7.-,.    li.j.   i\. 

'  ••  H.-[iartiti..n  (1,-  la  H.'-vn-  typli..i(k-  i-n  KniiK-i-,  Ii,;  ,1.  iiiir.  Cumiti  .■,.„^„l:. 
il  /iijih,  IWPl. 


m 


ryriiniit  lEvim. 


i-itliir  iiiiirc  iVcijiii  iitly  t!i;ni  wniiicii.  Wlictlit  r  tlii>  (linriciuc  i>  due 
:i<tii:illy  1(1  tlic  (•<iii<liliiiii-  ot'  -r\  ;i|i|)c;irs  mure  tliMii  iin|in>l),ililc.  Of 
(It'll  riniiiiii'^  inlliiciicc  in  tlic  cm-c  dl  tiicii  i-  |ir(il);il)lv  the  jj:rcat(!'  i)|i|i()i- 
liniiiv  tirr  iiilrctidii,  ill  tlic  |ir(-ciici' of  (•(jii.il  >ii-cc|)liliilit\ ,  hv  rcnxm  "t 
t:i(':il(i-  \  ;iii:iliipiis  ill  rc-idciicc,  in  niiti'ition,  :iii(l  in  occnjiiilidn.  Tliiit 
tlic-c  ciniiiii^tMncc-  (Id  iKit  iilVcct  tlic  st;iti>tics  in  jri-ciilcr  device  i-^ 
iindiiiilitcdly  diic  tn  rlic  liict  tiiMt  tlic  |ii'('(l')iniii.int  influence  of  WMtci'  in 
tile  di-^ciniiKitidii  (if  tlic  di>c:i>c  :incct>  wdincn  in  x'mi'ccIv  Ios  dcyrcc 
tliMii  it  di>c~  men.  Mention  of  tlic  tiict  furtlier  >liould  not  he  oinittcil 
tli;it  in  lio-|)it:d— t:iti-tic>  iiimIcs  pfcdoiniiiMte  soiiiewliat  liecailse  tliey  enter 
ho>|iital>  more  icadiK  ,  and  tlicfcfofe  with  rclativcK'  t.'^i'cater  tVe(|iiencv. 

If  ill  certain  ioialilies  there  i>  a  iiiarkeil  iiiajoritv  of  caso  in  males,  tins 
(if  ilselt'  iiiilicates  iMitliiiiir.  l)Ut  r.itlicr  re(|iiires  iiivistiiriitiiiii  into  tlie  nature 
of  tile  |««|iulaliou.  Tlius,  for  instance,  it  cuii  i)e  unilerstooil  that,  in  places 
that  liy  reason  of  lar;re  estalilisliiiients  or  I'actorics  attract  voung  males  in 
es|ici'i;d  niimlier,  this  fact  uuulil  receive  expression  in  the  event  of  an  epi- 
demic of  typhoid  fevec  in  the  L'reater  lumiher  of  males  allacke(l.  Murchison 
lielii  ved  the  two  sexes  eipially  susceptihle.  AiiKini.'  'IV-Vl  cases  treated  in 
till'  London  Fever  Hospital  hctwccii  \>^AX  and  IMil.  there  were  1211  males 
and  lliL'l  females.  Also.  JJartlctl  '  oliserved  llTlt  males  and  IKil!  females 
amoiii:  '-■W'l  ca.scs.  Althou;:h  Fiedler"  oliserved  'u  A^  per  cent,  of  males  and 
VIA  percent,  of  t'ciiiales,  this  may  airree  with  the  usual  proportions  of  the 
two  sexes  received  into  the  lios|iital.  Anionj:  22.'!.')  eases  of  typhnid  fever 
observed  in  Ilamliurfr.  I  have  found  211.'*  males  ((15..")  per  cent.)  and  1117 
female.-  .  •''>4.o  per  cent.'.  Iiut  teel  justitied  in  stating  detinitely  that  this 
pre|)()nde ranee  of  males  is  not  the  expression  of  a  iliHereace  in  predisposi- 
tion, hut  is  liic  result  of  local  conditions,  leading  to  the  admission  of  fewer 
women  into  the  hospital. 

Sinic  writer-  on  pediatrics  (West,  IJartiiez  and  Uilliet,  Tanpin) 
helievc  that  the  ditfereiice  hetweeii  tlie  sexes  with  relation  tii  predis- 
position to  the  di-case  extends  into  ('hildlKKxI.  .Ml  oliserved  tiiat  more 
lioy>  than  girls  were  attacked.  .Mthongh  it  is  not  at  all  clear  liow  such 
ditl'crences  can  arise  prior  to  the  jieriod  of  sexual  (ievelo])ment,  the  Col- 
low  inir  tigiii'cs  are  striking:  IJarthcz  and  IJilliet,  SO  hoys,  .'il  girls; 
Taiipin,  S(i  lioy-,  ;',.■)  girls. 

I  liclicNc,  liowcver,  that  these  tigiires  are  too  suiali  to  exclude  acci- 
dental influences,  and  that,  therefore,  they  do  not  sustain  the  general 
statements  hased  ii|ion  tlicni.  M'ith  a  niuch  larger  tlelil  for  oliserva- 
tioii-,  I  have  not  lieeii  ^truck  liy  the  pre) Minder; nice  of  hoys,  .\inoiig 
\'>\  children  siitVcring  from  typhoid  fever,  I  ohscrved  only  a  few  more 
male-  tli.iii  females,  namelv,  2o(l  hoys  and  2<ll   girls. 

To  what  degn  (  accidental  influences  may  he  operative,  even  with  figures 
much    lartrer  than    those   previously  given,  was  shown    ii-  considering  sepa- 


(  iti'cl  liv  .Muri'liiscii. 


'  L<> 


lyiKiLoay 


61 


rutely  f..r  cacli  ymr  llif  I.")]  cmx-.s  oliMTv.-d  in  cliil.lrcii  rlnrinj-  tlic  vcmps 
ixsii  anil  |s,s7  i„  Hanilmrtr.  It  lluii  a|i|.ciir(d  rliat  in  lM,s(;  i|„.ri."w»Te 
altacki-il  llti  ixiys  anil  M.s  L'irls;  in  Ih.hT,   l:U  |„,v.>  ami  11:!  j;irl>. 

Certain    ])liy-.i.p|(.iri (iitiuns    in    wntncii,    as    pregnancy,    tlic 

puerperal  state,  an.l  lactation,  ai)|..ar  t<.  (limiMi-ii  ihr  |,n(ii>- 
|H.sitiiMi   to   ly|)lioiil    r.vcr.      With    ivirinl    t..    tlic   lic-nr   .,f  iniiiiiiiiitv 

"""'''■'■'■'•''  I'y  t'i'-«'  -tales t    incon-iilcraMc  ditVrrcn.H-  ,A'  opinion  exi-t 

anion^r  various  aiitliorilie-.  ( ;rics.-iiij.r(.r  i-on~iiicrs  ty|ilioi.l  (ever  cxcikiI- 
mi:ly  rare  iir  tiie  |iiier](eriinM,  ami  lie  lieiieve-  niir-inir  iiitlmt-  al-o  tu  l.e 
|>artienlarly  immune.  In  this  res|«H-t  he  i>  in  aeeoni  with  Uokitaiisky. 
I  have  aKo  oh-erviil  ty|ilioi(l  infeetioii  hut  twice  in  the  piier|M  riiim, 
anil  Imt  rarely  .hirin;;  hiitation.  With  reirani  to  pre<:nanev,  in  a^ree- 
•;>ent  with  Lieiiernieister,  I  do  not  i)elieve  that  the  ininninitv  i-  at  ail 
eonsidei'alile. 

In  Ilaniltari:,  anicmi:  1117  women  .Js  were  preirnant — :!.4  |H'r  lent.  In 
inv  exiK'rienee  at  jA'ipsie  L'  |ht  eent.  were  preL;nanl.  Kven  at  tli..-e  period;* 
of  life  in  which  tiic  predisposition  to  the  disease  and  the  ciiances  of  prej,'- 
nancy  are  diminislie.l,  the  fii,qires  are  relatively  liijrh,  as  llie  Ibllowimr  tahn- 
lation  of  the  •'!«  Hand)iirLr  eases  will  show  : 

Sixteen  were  l)etween  the  ai'es  of  lifteen  and  twentv  vears  ;  lo  lietween 
twenty-one  and  twenty-five;  10,  tweiitv-six  and  tliirtv;"4,  thirtv-one  and 
tiiirty-tive  ;  o,  thirty-six   and    fortv. 

Hrief  reference  may  l>e  made  here  to  infe<>tion  of  tlie  fetu-  with  tlie 
typhoi.l-l.aciliiis.      I.ym'h,'    who   has   rejx.rtiKl    1     case,  from    the  iieart's 

'■' I.  sp.een,   and   kidney  of  which   the   typhoid-hacilhis   was   isolate.!, 

and  also  1  ca>e  with  entirely  iieir.-itivc  tindiiijrs,  lias  carefnilv  reviewe<l 
the  litci-atiire  and  coliceted  1  (i  niuloiihteil  cases  in  whii^h  the  tvphoid- 
hacillns  was  isolat<'<l  from  the  orj,raiis  of  the  fetus.  In  none  of  these 
cases  were  intestinal  lesions  found.  Anionjr  the  earlier  eases  niav  he 
mentioned  those  of  Kliertli,-  IFihh  hrand,-^  and  Kriist.'  He  has  alsoCol- 
K-cted  1  4  cases  in  which  very  careful  examinations  were  made  with  entirely 
tiee;ative  results.  From  the  existing,'  evidence  it  is  prohahle  that  infec- 
tion of  the  fetus  is  not  the  usual  se<|iiel  of  typhoid  fever  in  the  mother, 
hnt  that  favorin-r  conditions  must  he  additionally  operative.  Thus,  in 
the  ease  of  Ernst  the  mother  had  fallen  iluriui:  prcirnaney,  and  it  can 
readily  he  conceived  that  in  <'onse<|Uencc  of  the  traumatic  laceration  the 
placental  was  rendered  permeahle  to  the  hacilli.  Probably  the  most 
favorinj^  factor  is  to  be  foimd  in  the  hemorrhajric  infiircts  of  the  pir  .  nta, 
whicli  have  been  usually  notc.l  in  the  cum's  with  iH>sifive  findinj.rs.  In 
Lynch's  ])ositivc  case  tlxTc  w(  re  flaind  numerous  mi(Tosc<i|)ie  heiuor- 
rhaLde   infarcts,  while   in    the   netrativo   ease   none   were   found. 


'  .lliiis  Jl,,p/;;„s  l!ny,K  IhilL,  vol.  xii. 
'  /'"'/.,  IHKii,  Hd,  vii. 


*  Xiiilhr's  llritriiiic   ISd.  viii.,  .•<.  188. 


wmm.'^aB 


Ll*~'      i- 


•;■_' 


ryrimiK  ri:\ri:. 


Constitution  and  Social  Conditions. — U  lili  nLri"!  t<>  con- 
stitution, :ill  (ilp-<T\(T-.  ;ii;r<T  lliMt  |v|iliiili|  ti\r|-  i-  dill'  nl' |li(,~r  (Ii-c:i~cs 

llllll    niTlir    uitll    -|i.ri:ll    liMi|illi-~   Mini    t'i'i  ( |  III  IICV     ill    U  i  I  l-lli  ill  I-i~llri  I     \nlllli_r 

|(ri-i«ii-  -iliiMliil  aiiiiil  t:i\  iiialilr  liVi;iiiiic  -iirrniiiii  liiii:>.  In  tlii-  rr-iHrt 
t\|(liiiiil  \\\iv  -I  iinU  ill  i-oiitni-t  with  l\|iliil-  ti\iT  ;illi|  rrliin-iinr  t'i'Vrf. 
\\  liilc  ill  l:il;ii  r|iii|rliiii'-  iil'  llir  tVMi  Lllirr  ili-f:i-(S  till'  |iiMiri'|-  i'|:i~«i'-  in 
the    rMlluiilinilN  ,  1 -|ii  riiills     tliu-i'     l.iliuiiii^-    iiiiili'i'     |)1|\ -iriil     ili^lrc-^    Mini 

'^riii'iMlly    iiM|i,iii'i   I    iiiiliili MIT    MitMrki'il,  I\  plioid    ti'Ncr    ili'iiiMinl-    \\< 

-iiri'iruT-  Mlikt'  tmiii  jiiMii'  :ini|  rii  li,  iVuiii  iii.^li  miiiI  low.  ( 'rrlMiii 
ti'Mii-iliiry  iiH'iitMl  Mill!  |ili\-irMl  riiiiiliiiiiii-  M|i|ii'ii'  III  iiH'iT:i~i'  llif  ]iri'- 
ili-|iii-ilicin,  -iii'li  M'  |iiiiliiiiiiil  I'iMiitiiiiiMl  ili-liirliMiicc-,  i,nii't'.  i'mit,  mimI 
('\i'i'--i\  1'     |ili\-ir;il     Mini     iiiiiital    :ii'ti\il\.       Wlii'tiici-    iIicm'    iiilliicni'i'- 

li|H'r:lli'  iiy  liiUI'I'illL;  llll'  I'l'-i^tMllrc  In  lllr  ill\M-iuj|  ut'  tlll'  |Hli-llM  111- 
li\  t;i\  iii'iin;'  ilii'i'i'tl\  till'  rii('|iliii||  Mini  i|r\  ilii|i|lli  m  ill  llic  iiI'LlMn-  nl' 
tin-    liiiihj    i-   M-    \  rl    -liriiinliil    in   ilmilit. 

'I'lic  mode  of  living,  whirli  ]<\a\-  "<  ini|iiirl,inl  a  pMi't  willi  I'rlMlinii 
tu  till' ili'\  i'|ii|)nnnl  ■■I'  typliii-  ti'\ir,  Iim»  Ii\  no  mh'mii-  tin-  intlinnci'  ii|ii'n 
ihr  i|i'\  i'lii|inn'nl  nl'  I\|i!iMiil  ti'Mi-  tliMl  \\m~  tii|-iin'i-|v  Mtlriluili'il  In  il. 
While  rrnwiliiiL''  in  >iiimII  rnniii~,  ili'licimrv  nt'  Mir,  li';lil.  Mini  xrntilatinii 
im  Trn-i' ilii'ri'lly  tin'  cMpMliililN  nl' inlii'tinii  Mini  ili--i'iiiinMlinn  in  tlir  ra-i' 
111'  ty|)hii-  tr\  rr.  I  In '-I'  iiilliit'in-i'-  M|i|itMr  tn  111'  n|ii'rMti\  I'  iiiiK  I'liinlitiniiMllv 
in  t\|)liiiiil  I'l'M'T.  In  i-iiiinrclinii  uilli  tlir  hitlir,  il  i-  tn  lir  imti-d  lli;it 
ili'l'i'iti\  I'  linii-i'linlil-iiiinliiinii-.  MPc  ii-iimIIv  m— iiiiMlcil  mImi  willi  iiii|H'rr('it 
ili'MiiiMLii'  ami  |ii'nvi-inii-  liir  i'li'Mii>iinr.  iMilnr^  that  l'a\iir  the  .•ic('i<li'iital 
IrMII-li'l'i'in'r  n|'  till'  |Hii~iill  tn  Ml'tii'lr-  nt'  tiiiiil,  tn  I H'\  rl'Mi;i"-,  Mild  tn 
linli-i'liiilil-nti  ii^il-.        riiMl     l\|ilinid    li'\rr.   \\  Inn    mirr  d('\  i'ln|M'd.   inM\    lie 

iiiMtrriMlK  and  iiiil:i\nralil\  intliicnriil  in  it-  mnr-c  liv  iiii|ii'n|ii'r  -nr- 
rniiiiiliiiM~,  :i^  vvill  as  liy  dct'crts  in  cuii-titiitinii  anil  iiii|)rn|)('r  iiiiidi> 
'il'  lit'r,  i-  a  iiiMtti  T  III'  daily  nloiTvatinii.  SimilMr  >tatrincnts  iiimv  lie 
ni  nil'  in  '^I'lnral  \\illi  rriTMi'd  t<i  -ih'ImI  |Mi-itinn  and  iirrii]palinn.  In 
t!ii-  rr-|ii'it  al-n  a  crrtaiii  rniitra-t  tn  ntlirr  int'iTtinii-  di~rM>('>  i-  tn  lie 
<'in|iliM-i/i'd. 

'rv|lllnii|    fcVi-r   i-    lint     riilllilll'd     tn     jlnViTlV   Mllll     llli-rr\'    Mild    till'   rnrri'- 

>|pnndiiiL;    |iii\-ii'al    rninlilinii-.       I  ii  dni-i'K'    |)n[iiilMtrd    ritii Mild    tlic.-c 

inn-titiitc  till'  lii'-t  lirld  I'lir  nli-crvMtinii  ill  tilis  ciimn'ctinii — t\|)liii,-  lexer 
and  rila|i-iiii:  t'lM  r  iiuadc  tlic  liniiii'-  lA'  tlie  [MHir,  asyliini>  and  [Miial 
in-titntinii-,  unrklinii-i'-  and  jMil-,  and  a\niil  tlir  dwi'lliiij^s  nf  ilir  riili  ; 
while  ty|ilinii|  t'i'M  r  liiiU  tn  recnLini/e  these  liiiiilMtinn-,  and  neeiir-  as 
riei|Hently.  if  imt  ninre  I'l-eiillelltlv,  anniiii^-  the  lielter  elas-es  ui'  siM-ietv  lip 
t'llhe  lii;;lie~t  eirele-.  The  "  lllisere  |)liysii  i|n^ii|ne  "'  all'nnU  |)nit<'etinll, 
in-tead,   at;ain-t     the   di-ea-e.      The    speeial    nlaliniis    nt'    nei'ii|iatiiiii    tn 


i:niii.in;Y. 


63 


ty|.!iMiil  fever  arc  ti>  !)<■  conxid,  n  il  In^ni  tiii-  -taiiil|Miint.  Aiiinii;:  iIjc 
workinir-clii.— (■>  tlir  viirnroii-,  soimi:  iinli\  iiliial-  li\  iiij,'  iimiir  Ixttcr 
(■i>ii"litinii^  anil  (•iit;a>;i(|  In  nmn-  liialtlil'iil  |iiir-iiil-  arc  with  |int<nnif 
attai'kcil.  A  "iK'iial  |>n<li.~|M)-iil(>n  i- ((.nlirnd  c.nly  \>\  iliu-.c  iicciipaticms 
lliat  iiiHc~~italc  ilipMt  cxiMi-uri'  to  ilic  inva-iim  nf  tlic  isplioid  vini>. 
Ill  tlii-  cJa-^  licjuni:  i-|i'rially  iIkim'  riii|iliiycil  alxiiit  aii<i  n|Hiii  tlii' water, 

a-  laJMii-dv  in  liarlM.f-  ami  -laiiini,  a-  well  a>  all  wli.. •(■ii|iati(>n  hriiiir^ 

tlieni   in    cuntait  with    |.atiinl-   ami    their   (lejection-.  naineU ,  |ihv-i(iaii-, 

nurses,  laiiiiilre>-e-,  <li-lnle(tors,  and  «..ikniei eaiiaU  and    in    -e\ver-. 

Ill  addltidii,  -iieh  i>eeii|)ations  ainl  ((iiidit icii-  de>er\c  e-|ie(  iai  niention 
that  neee»itat('  intimate  a-uciatinri  of  iiidi\  idiial-  |ihyMeailv  |>rcdi.-|)<)M'd 

111  marked  dejrree,  as,  Ci    iii>ta ,  interne-  in  ho-pitai^,  pupil-,  in  seliiK.l.-, 

Mihliers   in   harracks,  etc. 

The    (|iie.-tinn    ut'    hospital-infection,    prevlou-iy    ret'.rre<l     to,    is 

W(M-tliy    III'   iiKire    detail.d    i -ideiation.       It-    tre(|iienev    i-    extretne   at 

ditl'erent    times  and  in  ililVereiit  in-titiition-.       The   modes  df  eonveva'ire 
from     typhoid    patients    to    other     patients    or    to     heallhv    Individual- 
ran     in    u'eneral     lie    only    the    -aine    a-    tlio-e    under    other    eonditioiis 
I   iifortnnate  aeeideiit-,  a-  a  le-iilt  of  wliieli  the  poi-oii  jiiveii  otf  from  the 
patient,  and  eont.'iiiiid   e-peeially  in   th<.  ik;je(tlon-,  trains   acee,-s  <lireetlv 

or   indirectly  to    the    i itli  and    the  diire-tive  tract  from   the  hands  and 

tlicciotllinjr  of  the  nilises,  or  from  illfecte<i  articles,  holl>elioM-ntciisil-,or 
from  articles  of  tl.od  ami  drink,  |)lay  the  mo-t  important  /•.;/,■  i,,  this  c(.ii- 
iicction.  The  fre<|ni  ii<y  with  wiiich  cases  of  ty|.h(.id  fever  originate  in  a 
lio-pital  can  therefore  l.e  taken  as  an  index  of  its  iiyi:ienic  arraiiv^einciits 
and  the  oivaiiizatioii  of  the  medical  and  ninvintr  service.  To  what  <..\tont 
c-p-cial   -verity   of  the   epidemic  or  .spcci.al    p..r-,,nal    -n-ceptihilitv    is 

"!'•■'■■"'■<•'■    i"   llii>    inceti(,ii    is   n,,t   yet   clear,  hnt    they   are  not   t.i   l)e 

wliojiv    ii.'-iiored. 


I 


At  times  a  liospilMl-cpi.Jeniic  that  results  from  the  mistake  of  a  »hMe 
iiiexpcricMe.Mlnr.'aivh.ss  assistant  may  upset  the  hest  iivirieiiic  rc-ulati,.ns. 
We  liave  receiiliy  ha.l  such  an  nnlortmiate  experience' in  I^'ipsie  in  this 
ci.micction.  In  Hamluii-  where  the  hv-ienic  conditions  of  the  ho<pital  are 
most  adnurahle,  I  ohserved  in  the  vear  iMs;,  the  vear  of  the  most  severe 
epidemic,  only  21  eases  anion-  the  inmates  of  the  hospital- aiiont  0  r)? 
l)er  .•eiit.  Anion-  these  tluTe  w.tc  oiijv  11  who  ha.l  prcvionsiv  hen 
patients  in  the  hospital,  thus  ahoiit  O.L'.S  per  <enl.  AmonL'  these  11  onlv 
•J  had  occupied  the  same  ward  as  other  tvphoid  patients,  whil..  the  remain- 
der ha.l  a.'.piir.Ml  the  .li.sea.se  in  the  sur-i.^al  clinic  am!  \\n-  skin-clinic,  pn.ha- 
l>ly  throu-h  the  mtermcliation  of  some  thir.l  (x-rson.  .Muivhis,.M's  experi- 
en.e   in   the    l.on.|..n    Fever    H.i.spital   was  al.-.)  .piite    favorahl,'.    as   amoii- 

l<U)4.s  ,.ases  of   lypi |   fever,  hut  "J   wr..  .,f  h.ispital  .)ri-iii.      The  experU 

ences  .,i    other  li,>spilals  have  heen  .s,.mewliat  less  favorahle.      In  the  dacohs- 


__ 


'  -.fj      -  -     t-. 


- 1  r.  =^.- 


J  A 


64 


Tvriinih  I  i:\i:n. 


\) 


f  ' 


s|iil:il  (if  I.(i|iKi('  '!.'(  rnsc^ — L'.l.i  |)i  r  criil.  df  niisiicniiiiiil  Ivplmiil  (('ver 
i](  I  urrcil  ill  ihr  riMii>i' lit'  tiiurlccii  vrars.  Ilcic  tin-  iiiiixs  ami  lln-  ii>,-i>l- 
aiil.-.  aiiiiiiiL'  uIh'Iii  L'.>  ra.-c-  mTiirri'il.  Wri'f  plaiiil  iiinli  r  far  iimmc  iiii'aMir- 
alilr  cniKliiiiiii.-  lliaii  iliiix-  iiiMlcr  llicir  care,  l.irliciiiM  i.-u  r  liail  an  iiiiii>i 
similar  i\|irriciirr.  oIimtn  iiiL'  aiinniLr  I'.'Hd  ca.^o  idiinn;:  I  In-  \car.>  liinii 
iMi.i  i<>  1>7I'  1)  J.  I  |nr  iinl.  I'lic  f.\|ii'riiiiri>  i.T  A  k  xaiicUr  al  tlir 
Hrc.-laii  I  |ii.-|iiiai  \\<yf  ll■^.-  t.i\  uralilf.  \\  ca.x-s — :i.()  |iir  cent.-  dt  ikimi- 
comial  iiiiL'iii  licinir  nlr^frvfil  aiimnir  ■•'■'•'l  |ialiiiit.-.  Tlic  i'.\|p<ricii(ts  at  Kirl 
\MTc  I  ill'  mo-t  iiiilavunilili'  i  <  iuili '  i.  iiamcU  .  .p..)  |i<r  ci  iil. 

Ill  till'  .liilui>  ll(i|ikiiis  llii<|pilal,  Hailiiniirc,  Jll  (■aM>  cf  Ivplmiil  fi  ,iT 
ha\i'  nriniiiatnl  in  llic  liii>|>ilal  >iiii-f  il,«  ii|iciiiii:;.  cli'Mii  \iar-  a:.'c).  Dmiiij; 
tlii>  lime,  11(10  casis  (if  |\|>liiiiil  fi-viT  lia\c  liicii  tnalc<l,  makiiiL'  llir  |n  r- 
cciilaL'f  nl'  I  aM-.-  (if  li(i.>|iilal  iirii;iii  \.>^\.  <  M'  llioc  iiifccicil,  >  ucrc  iiiirM.-*.  •'> 
|iliy:-i(iaii.-.  7  paliiiil-.  1  (irdcrly,  and  1  maiil.  l-diir  (if  llic  7  (■a>(>  aiiidiiir 
patient.-  (icciirrcil  in  (inc  uani  at  tin-  >amc  lime.  I  lircc  cax  >  of  l\|ili(ii(l 
fever  have  (i(ciirre(l  aiudiii:  (liictdi'r-  ami  ^tlllll■llt^  Wdrkim:  in  llic  pal  linldiric 
lalidraliirv  nf  llii>  Im-pilal.  In  diie  ca-e.  thai  d|'  a  -liidciil.  a  pd.-silile  sdiirce 
of  iiifeelidii  eiiuld  lie  li'aeed  Id  ua-hiiiL;'  l(-l-tuli(>  (  uniailiiii^r  eiilliire>  df 
tvphdid-liacilli    wilhdiii    pre\idu>l\    -lerili/inir   them. 

(  )||  tile  wlidle,  my  (Npefiellce  -IkiU-  llial  ill  well-ciilidlleted  ll(i>|iilals 
i.-iilalidii  (if  lyplmid  patient-  i-  iidl  ii(i(— ai\.  (  )iily  iiiider  -peeial 
(■(iiiditidii-,  partieiilai'ly  when  llie  adniiiii-l  lative  arraiideiiieiit>  are 
iii-iil)ieieiit,  and  llie  relatidii-  lMi\\(('ii  ilie  adiiiiiii-lnitiv  e  and  ilic 
niedieal  dllieer-  i-  imeertaiii.  wdiiid  p(  riiiaiieiit,  (H'  at  lea>l  teiiipdrary, 
^, .Miwdalidii   df  tvplidid    p.'ilieiit-    ffiiiii    the    icinaimlef   be    re(|iiifed. 

The  aelidii  (if  cold  and  the  traii-itdi'v  Imdily  di-tiirlianee-  nferaliio 
t(i  il  .are  fl((|ll(Mtl\  lilelltiiilled  a-  faeldl-  fa\iililli;  the  (le\ cldplllelll  dl" 
typlidid  fever.  I"(ir  liii-  there  i-,  hdUexcr.  im  pii-ili\c  e\  ideiice.  aii(|  nut 
I'VcM  Ini-twdrlhv  -ii|i|Mirt  tia-ed  iipdii  e\peiieiiee,  which,  as  will  lie  -ccii, 
may  lie  iiiVdked  in  tiivdr  df  dtlier  cdiili  ilnitin;.'-  cdiidiiidii-,  I  helieve 
that  the  t:l-d\\tll  df  the  lielief  that  Cdld  la\(irs  the  de\ clolHliellt  (if 
txphdid  fever  i-  the  re-iill  (if  ediifii-idii  with  cdiiditidn-  llial  are  theiii- 
M'lve-  a  |>ait  (il  the  di-ea-e.  I  iii.-iy  iiieiitidii  in  ilii-  edimeetidii  the 
scM-e  (if  Cdld  and  the  swcatiiiLT  nf  the  peridil  (if  ineiilialidii,  a-  well  a- 
file  initial  ehillille— .  \\  hetlier  the  illllllenee  (if  Cdld  in  thd^e  alre.idv 
iiiti'cted — that  i>.  ill  the  pcrind  nf  ineiilialinn  nt'  In  plidid  fever — aeceler- 
ale-  till  diitlireak  df  the  di-ea-e,  a-  appears  denidiislnited  fur  a  iininher 
<if  ((ther  iiifeetidil-  di-ea-e-,  a-,  liif  ili-laiiee.  tilirilKills  piicliiiKinia,  is 
yet  (Idlllilflll.  The  eax-  -eclll  Id  iiave  a  |id-ilive  -iL;llilie,anee  ill  which 
flic  tii'sl  sviiiptdiiis  df  typlidid  fever  appeared  after  a  did  lialli,  nr  a 
fall  ill  wafer,  (ir  sleeping:  in  ll'c  dpeii  air,  etc.  These  eax-  are.  Iidw- 
cver,  liy  lid  iiKaiis  cdneln-iv e.  It  inii-t  alwav-  lie  Ixiriic  in  iiiiiid.  tiir 
iii-taiiee,  that  iiniiieisidii  In  iiifeetidii-  water  niav  lie  fdllnwed  direetiv  liv 
enli-iiiee   (if  the    pdixiii    iiitd    the    liddy   ;ind    rapid    develdpiiieill    (if    the 


-O    H' 


I   rin/jH.  )• 


(;., 


•''--.       In    lh.nl,,,,.,  II.,.,,,,,,,,,.    „, ,„...„|.,.„v...|,v,.l..,i,l,,.,.l, 

'""r":;-'";^ '  '-'■  -'• '  ^'^-,.  :,„ „.„  .„„,  „, ': 

Relations  between  Typhoid  Fever  and  Still  Existin.^  or 

Antecedent  Diseases.-. ,, ,  ^„„,.,  t,;.,.„,l"',- ' 

.-■■-:nv.,...,.v,,,.,,r.   ..i,,,,,,,i „„ ,.,^,,      .,,,^^^^.^_^ 

■"'    "":7l'^"-'""l-l>^"'l'-'il'nlM«no,|„,-,|,...,i,.,,.„,^ ^„,^ 

;!:■'';•,:'''';:'-'''■-'''; '■'•"''■''^='-' '^•"••' '"" '  i-.i.! 

';;":" '""■"'■■-—"-.I,..  ,.,;„„,.,„„,.,  „,.,.. ..,i,,.„;^.;^„ 

"""  T;'""''"  "■••  '"'■■I'-  ■■"' -Iin.i„,...l„.u,.nn ,1,.,  ,;,,.,, 

-I.lp.ol     tl„.,-,Mt,.„|..„l     ,|iH,,„,  ""- 

,'"    -■'•"••'l-'<-vi.ii    'I-  vi,.„   alr,.:,.|v  „„,„i„„.,|.  ,,.,„,|i,„,  ,„ 
:;:"-7'''^ -■;-•■■•'•-    i...li.i,|,.al,   an.   ■,•    ,.,.a.l,.v  a,,:..,     Z 

'•■^■'••-  '"•<•".-   ^I,..r.ly  at-,..,-  ,.unval,.-,...„..,.  f, , :./.•'':"' 


•"iival,-,.,.|i,.,.  tn.n,  a.it.v.W,.|ii    iMt;...tioi,s  .lis 


V  '■"".""■' ""' '"■■"'  '"•  '"-'"  -l-.inllv  ni-  a,„.i„..  .i„.„|„, 

•'I'l'-'^  "-'l.v  ia,;:r,.  s,aii>,i,.s  u,„|,!  |„.  ,,„.,|„^i^.,, 

„,,/', 'rr   '':","  :'T"^'   '■'"" '•— — >"n.llv  „.„  ,...n-.v,lv- 

■inta^i.iiiMii   t.itviii,,,     t;.v,.,-       'ri,U    I,.,     I  ,  <<'Min 

J-: /n J  ,:J;t ':;;:' 7' ""■'■:'•■'. 

II  '.     <  .111,(11     )     wild    ;  (|\  aiir(.<i   t  if  v  ..n- 

'•iM'ls   the   .l,.\,.|,,|„,i,.,i,  ,,      tvn  |,,i,|    ....,,,.         11        ,1  .    .  ' 

'>'" '  '■"■■■' ,:;;„;:■,;,:;,:'■"-"■'' 

1  11  ret*  fast'*;  rtt'mivitJ    ',,.4'     .*  •    I       1 

"t  tv,,l,„i,|   fever  tre'ie     ''"  '   ^^  "if '"-    ""^l"!"!   a-ioii,.  about  l|(H)-,.L..s 
•■'II.V>..,I    L>.,    uiil.,I    .■,,:•"'•."  •''   '•'•I""-'-'  ""<•  "f  tl.es,.  ,.a...s.  |,as 

"">■ '■-«' ;~ -:;;;..i:;i„'^i;l.::;!i-;-  !:;;i;- "  -™" 


'  /..■•/.„/..  .1/,,/.  ./,„„ 


.Illlv.     |H,-,,-,, 


'■''■''-  "'■/'^n,.  „..y.    It,,,..,. I    V 


■■   A'.r.   ,/ ,/..    IH.-dl. 


i     I   : 


(Hi 


I)  rimiii  I  I  \  I  t: 


\ ii,_r    ill,    rlin.in.     ml. ,11. .11,    ,ii-.:i-.  -    |i(iliiiuii:ii\     Iiii..ivii„.-i.    l,;i- 

.,(■,,1,   l.rrn    -|K.k,n  ..r  111    lln-   .■..iiii.rii..M.  iiiImt,  iiL.ii-    |..iIi.mI-    1- in-  ..i. 

tlir  «li..l.    l....U,.l  ii|M.ii  ;i-  |.i-..i.vi.-.l.      Al-.,  ;i..,.nlin.r  i >   ,A|Kririi.v. 

JM.IiM.liiiil-    ill  til.      liii.l.ll.'  :,M.I    .-|..vi,-,llv    ill   ill.     a.K:iii...l    -la-c  ' 'f   |'nl 

,1 ;i,s    i,,1hiviiI..-i,  ;iiv  .,irn.-  iiiivk  mIIii.Im^I  I.v    Ivpli-id   lix .  f.  I  ll.i- 

i,    ill,/, ,.    ii.,|,.u..lMliy   1m.,mii-,'    -lull    iKiliilil-    -.m.imIIs    ivium'  i    in    iIh' 

li.,-|,il;iK    r..r    :i    l.'ii'-'    lini.'.    :iii'l    I  Imi- l-iv    aiv    willi     ivhiliv    IV.  .|ii,  ii.x 
l,i-.,ii:;l,l    int..  .■..iilii.l   uilli  l\i.li..i.l   |.;ili.iit-.       ll    I-  '11,^    iiiilil-.--i'>ii,  li..«- 

,.\,.r.    thai    ill    lln-    .•.,iiii..  li.' -|,..ili.- Im I    'li''   l""'>    i"    '" 

|„.    |„U,ii    iiil..   .•..ti-i.l,Tili..n.    I'lil    lli:il    ll"'   .■ni:i.iali..li  ..r   ll..     l.aii.nt    i- 
,,„,   i,„,„,,,;,nl    ra.l..r,    I.t    pali.iil-   -iilV.rin-    tr-ni    ..lli.'-    .  lii-..nir    all''- 

,i..n-.,f  \aii..M-  Uiii'l-.  ll'"!!  niali-naiit  ii.'..|ila-Mi-.  ,lir..in.   < -liliiti..iia! 

,li-.a-.-,  aii.l  .-|M-,iallv  .lial.,'l.-,  aiv  -.aiv.lv  ,A.r  alla.'k..!  uiili  lsi,li..i.l 

tiv.r,  ill  -|.ili-  ..r  liv.|ii.iil  ,A|...-iiiT  I"  iiili-li-n.       In  liar ny  witli  llii- 

vi,,„  i-  il„.  la.l  tlial  u,ll-ii..iiri-lM-l.  af.l.ril.-  tnl,.'iviil,,ii-  pali.iil-  ..r 
in.livi.lilai-  uilli  lal'iil   Inlni.  iil.-i-  an    l.s    ii,.  ni.ai,-   iMiiniiii,'  |..  ty|,li..i.| 

tl'V.T.       K\.T\    .vlHl-i-iir,'.!    .•liiii.iaii   will    lia\,'    Iri.l    -.mir   ul n.v  'A]"- 

ri,.,„,-  uitli   'ivr.ivn.v    I..  111.'   .|,s,l..l.ni.iil    ..f  till..  iviil..-i-  ..r    llir    la|.i.i 

|,i-..oiv-  ..f  |.i-.Ai..ii-lv  iv....^iii/.-.i    .iivmii-.Til,..!  iiilllirali f  llic  Inii'- 

.luHn^r  ||„.  ,.,,ii,-,.  ..r  tv|,li..i,l  r.v...-.  M-.  ill.'  ■•tli.r  .•lir..iiir  -li-.a-.- 
.,f  til.'  lull-,  .iiililiv-nna  a.i.l  .lin.ni.-  I.P.n.liili-.  a-  u.ll  a-  l.f..n.lii- 
•  ■.la-is  apiH-ir  l..  iMliav...  uilli  ivlari..ii  I.,  tlir  lial.ilitv  ..l'  iMt;'.ti..ii, 
i„    ;i,v..nlan.r    with    llf    a-.-    ami    .^.-lunil     pliy-ical    .nii.lili I    lli.' 

|Kltirllt. 

(■lii.inic   (li-caH-   ..f  llic  n.Tv..ii-  ■  \ -t.iii.  in    -o  far  a-   tli.y  ..r.-m-   in 
iiHiivhiiial-  williiii   tlir   |.r.Kli-i"i-..l    i«ri...l  uf  litr,  an.l.  a- -..  ..ffn    iiap- 
|„.„-.  r.,r  a  Ini.i:  ti""'  -1"  ""t    '".i""    ''"    "■ii~tiliiti"ii.  MtV..fil   ii..  iinniiiiiilv 
t,>   tvpli.-i.!    t;.v.T.      'I'll.'    -tat.in.iil    lliat    .li.tcti.'    .rn.r    uitli    -.v.,n.larv 
tra-ir..-iiit.-liiial    .-ataiTli    -iv.-    ri-.'    t..    tv,,li..i.l    f.v.  r    i-    i...    Inii-rr    a 
inatt.T  fur  .li-.n-im.   at    tiir  pf— nt    .lax.      Tli.'  vi.-.v.  .•...i.vival.lr  tin.ii 
„„,.ai-licr..ti..l..i:i.'-iaM.llH.int,i-!     -.1  np-.n  an  iiu'i-rr,  .  i  i,it,.ri.ivtati..n  ..I 
vari.iii-  ,,I.MTvati..ii-.      Tim-,  ii    ■-  ■  ■  nainly  ii..i    iin.'"Miiii..ii    inr  ili.-  tir-t 
,-vin|.tnn,s    ,.f    tvi,li..i.i    Irv.r    i-    I"'    i-Mt..iin.l.^l    xvilli    tli..^,'    -f    ~iin|'l>- 
^ra.-tn.-iiit.Miiial'  ratarrli.      TIh   'ian-vf   i-  ,-i.r.-ially  -ivat  '.villi  nliivii.T 
^,  ,„.-.-... f  walkiuj:  typlioitl   liv.f.  wl,.,-c   tnir  natiuv  i- ..i>,n  ..nly  lii-t 
r.H-.,.^i,i/..l  wlirii    tli/i.ali.nt    i-  .•..ini"ll.'<l    t..  pi  t-  l"'l   after   a    ivla].^.- 
attcn.lnl  vitli   liiirh  f.'vrr.      Oil  ih-'  -tliT  liaixl.  it  .an    l-.'  na.lily  nnilri- 
M.mmI  that    . li.'t. ■tic  crnir-  with    tli.ir  .•..ii-r,|ii.n<'4.s  may  fa  v., r   ihr  1...1-.- 
„„,,„    and    il„.  .I..v,.l..,mi,iit  ..V  thr.-uutairiinn,  ami  it    i.  lint    ii.i|.r..l.aM<' 
tliat   it  inav  a.cchi-atr  the  ..iit'.ivak  ..f  thr  .li-.a>v  in  i.i.livi.liiaU  aliva.ly 
iiif^H'tiKl.      SiipiKirt   for   thi.»   view    i-  an;.r.UHl   l.y   tiic  ,.l,.-.rvati.m    that 


.(•    ivl 


I  lint. DC  y. 


i|'-'~    ami     iniiii 


67 


nl.iti  '   I. 


lint     ninlv    (liiv,il 


iHiitii'  crrni-. 


I 


"■  |"<'li»|">-in_'   iiitliji'ii if  iiiiili-  iiikI 


I."    iiruliMli 


Iv  .1 


•  ■["■iidrnt  ii|»>ii    III.'  all.-ialinii  in    |n,|r,„.| 


I'hroMic  iliw;t.Tj<  nf  ||io  ni. 


wliKh   ilicy  iriM.    n.<c.      Ai rilin- 


ilivax  .  iiivailiiiL'  Ilic  ImhIv  llirDuirli  ihr  d 


to  iili>fr\atiiiii'<   iiiailc   i 


ilorii-  aciil  siir,tj(,|i 


II  iillicr    rit'ri|ii)iis 


iliili.-i|iatc.l.    .\fllinii:/|i,;i,|ii,.,  Ik 

iwnr   i-i>i-iaiil    iliaii   iitlii 

KMMrir    jiiic-,..  ii  caiiiiul    |,r  iloiihh'.l 


i;;(v<iivi'  trail,  tin-  h:i,  t,,  |,.,\, 


iilinM.il,tlictv|ili(,i,|.liaiilliiiirr.lalivclv 
I'lL'.iiic   iiiicin-orL.'aiiiMii.s   tM   till'  iii'tioM   of  il,',' 


'■'iii>i,|,.|-:ili|i-  iljiiiiiiiii 

-ai; 


ili'Mi  III  till'  frci'  lnilriM'liI 


that    tiaiMitiirv  or   i.rolraclcil  alifc 


liaiHJ.   I 


■'I'l'-lll'''      llllo    ill,'    i|||,-li||;ll     ir 


ri 


>n('  arid  iiiat.'rialK   t; 


"•     M'-IIIIICi 


I'lirclirallv.  it   i 


IiIhiiii'Ii  lira 


iiav,  mi    till'  ,ii 


iMirs  itii-ir 
till 


Ml 


llll'll     Itl-O.'l, 


li'd.  llial 


I'M.li'iiii'  III  faviir  of  llii.'.  vii'w  lia.*  mil 


ri'laiivi 


olrii'  ili-iii'ili-is   atlcmlcil  \\\\\, 


iiiirliaril  am 
•  •liaiiL'-i'.<    ill    till 
•_'a.<lrir 
il 


|inili'i'lii.ii  a:.Miii,i    ih,.  l\  |ilii,i,i-liai'illiis.      ( 


I  |K'rarii|iiv  ad'iinl 


lii^   |iii|iil  Li'  fMiiili',.  '  i'iii|i|,;i,.i/.c  iiiav  I 
ipialilii's   of  III,.  ;','i.>irii' 

■"lit, '111.-.  Tlll'V       U'lil'M'      ||„.      .1; 


rtaiii    iili.it'rvalliiii.-i    that 
11'  ill    ari'oril  witli    t|i,> 


jiiii'c   am!   Ml    II 


liarai'icr    nt    il 


aliiiiii    III)    |i,.r 
liilalalimi  of  tlir  -im 
ai-li   :_'fm'rally  cxliili 
alisi'iii'.'  or  ili'lii'ii'iii 


•r  all    t\plioi, 


li'tiH'iit    jii-iili,',|    ,  I.,.  (;,.i„| 


•II.       .\.- 


|ialii'iii-    laiM'    III 


t    iiiarki'il   alliral 
\   ill  fri 


|iali,'iit..<  with  cliroiii,'  ,1 


n- •    that 
i'\ioii.-i\    .»iil|i'rt'i|   Iroiii 


mil-   ill    ll 


llalalioii  of  I 


If   .•loiii- 


lm'iit.'<  'll    ll 


lyilriicliionc   arn 


lo-l-    oIlSiTVlT-     iiiav    I 
I'Vl'r,    oil    ill,.    liM-i-   of 


I'Himl    ill   llli: 
iiiv  own  rliiiical   ami  aiialoini 


I.    -a.-irii'   |ii-        |iartii'iilarly 

an  i'X|ilaiialioii  for  ||i|.  slalc- 

liri'iiiii  .laiii'c.      I    (ill  I'Diii- 


>  'li'iiv  Hii'.-i'   -lati'imiil-  ,'iii|ihati('allv.      'l"|ii'>o  h 


ill 


ll'  ililalali if  III,'  ,-i 


I'lallv    roniiiioM. 


lio 


I 


'iiiai'li   ami  ty|ilioi,|    f,.v,'r   i.-  Iiv  i 


(•  i)i>-i'rvaii,)n.<, 
ivf  .-liiuMi   that    the  coini'i- 


"11    iiiialil,'    iliriii    al.'.,)    ilic    fiirt 


1(1  iiicaii.'*   r.«|ic. 


Ii.inl  ami   I.,.  «  Jnnlr,.  that    tv|ilioi,|  f 


caii.-ii'-  ililalation  ot'  tli,.  >iiiniai'l 


I  III  iiri'Vioii-Jv  hi 


■r,  on  till'  othrr  liaml. 


KT   .-lalcim'nt    of 
Mot     r.ri'lv 


Repeated  Attack  ;  Immunity W 


|).,— ,.— II 


I'liiiuniital  iniiiiiiiiitv  tu  iiifiK'ti 


hi'tlicr  tliciv  arc  iiiijiviilnal-i 


.\t  all 


iml  Vet  llll'll  ili'tci'iiiiii, 

(■veil  ll—  rrn|ii(.|it   tliaii  i-  k 

•  ■a-i-,  |iarticiilarly  tlio  acute   I'.xaiitl 


111  Willi  the  tv 


pimiil   I 


•'vcnfs,  till-  i-  cxtrciiicl 
tl 


V  r:irc, 


Hll-nll    lla.-i 

|icrha|) 


l^iiiiwii  to  l)c  the  ea.-e  for  other    iiireeti.iii...  di- 


lirmlv  e-tahli-heil  nli-, 


■mata.      On   the  otl 


ler  haiiil,  It    1-  a 


I-: 


■r  eimter-  relative  liruteetinn   t 


■erv.'iliiin  that   recovery  fhiiii  mie  .',ti;ick    of  l,-i,||„i,| 


iMi 


elli-oll,  .low, I    to  ( 


(  Kreti 


I'liiii  -illi:.e(|iient  atta,  k-   of  the  d 


l.<ea.-e, 


ilieaii,  (  'lioniel,    I, 


mis.  Hiidd,  .Feiiiier.  Mm 


Well   a-   al 
illlliilliiit\' 


■ne-iiijrer)arc  iii  aorceineiit  a.-^  to  thi..^  fact  ;  hut  fl 


lev  a,-^ 


more    recent    oliserv 


I)r.i|ierly  einpliasizi.  tile  fiict    that   th, 


"''l"ii' >v  nvuvery  lioni   an   attack   of  tv|.li,)id  ( 


e\('r  IS  not 


• '""•'"■"■■'  "^  ''='^  '"■<■"  -''"^v"  '"  I'.'  the  .'ti.-e  Cor   nio.<t   aci.t.'  e.xantl 

iiata.  iiicliidiiii.r    ty|,|:ii-    fi'ver.       It 


'I'K's  not  cNtciid  til 


IS   certain    that    in    inai 


th 


iy|iliui,!    fever  ennfer-    more   ma 
d 


ll^-'lliillt  till    whole  of  life.        Whetl 


ly  jierMiii-    It 


rki^i 


liin    mild   ca.-e.-   j,-    nnknuwii.      Ti 


ii1d 


er  a  severe  attack 
iii'ire    protr.icted  pnitectioii 


^\peru.IKe-  in  other  iiifivl ion- disc 


lis  would    net    lie   in   aeconl  with  tli. 


vases,  and  al-o  with  -unu'  recent 


l>i/a/„l,,,H  ,/,■  fistuiiKic  i-t  liirrr  ti/,,/,,„,l,- 


e.xperi- 


w,'  ,  Tli,'M'.  V. 


rU.   IHKi;. 


! 


3  r- 

I 


a;-^!^ 


68 


ryrii"ii>  ri:vri:. 


,„.„t;,l  nl,-..rvMtion-.       Ar.-or.ii,.-  t-.  n.v  ou  n    ..x|Mri.n.v.  tvvu  atturk-  .,f 

tvplini.l    f.v.r    in    tl.r   -Minr   ih.-i.   ..v   l.y  >. an-    nuv.       I  lu.v   n.v 

..;..„  in.livi.l.uU  wl.n  Imv  l.a.l   Ilnv  ur  luur  atlark-  .luni.j:  thrn-  liv.-. 
Surli  ail  .KMiinvii.v  iialurallv  i-  a  rare  cNcri.tioii. 

\,„„n"  1^^>  nati.nt.  .xaiaiiR-.l  will.  L-nat  car.,  i.,   nranl  t-  this  i.niMl 

durin.  ,1,;   .i<u\Lr  in    IlaM.lmr.'   in    issT.  .Iut..  wcr.  ..-I   n,   t  uMr  ..nM..l 

;a"^14  ,1,-  .■.-....      On.   pancn.    .a.  .i.i>  ,vv.a.   .y  n,   ■'•>-,     a.^k. 

\,u.MP'   llu'^l   :)4   nalicnts  lli.rc  vvcrr    1-  «lio.    -Inrn,-   iIk'  tu>t   atta.k    .t 
K   l,ia   r.v.r.    ali    haa   l.vn    nvat.,!    in    th-   (icncrai    Ilos,„.ak    an,     .1,.. 
i  ,:,„..,s  ..onl.l   1..  v..nii..a   iVo.n   .1..   yu..r..,\   ins„„-,.s  an,!   U.uyruaun^. 
I'l'ar,..      In   th.  n.nainin.'   :W  the   stal.Mn.nl   «a.  a.-Hpna  ..niy   Nvh.n   the 
eviaeiire    \\a>    most    |.n>ilive. 

•l\,,h.n.l  fever  pn-ent-  a  noteworthy  .litV.ren.r  from  the  a.iit.^  exan- 
themata in  the  faet  that  eon.|.kte  immunity  .k.e>  not  exiM,  as  in  the  hitler, 
,h,ring  the  first  ,H.rio,l   .Iter  the  .ri>ease,  ana  tlial  ,.ro.,v->ive  .Innmi.tioii 
,1,K.-   not    -Ml.M,|Uentlv    tak..   pki.v   in    i,ro,K,rtion    to    tlie   tune  ekip-m- 
,,,•„,,  ,,„,   ,i,..,   .M-,rk.      On  ti...  .•ontrary,   I    have  ol.>erv<.l    imlivMhials 

„m,k..l  t;.r  a  s..eoml    tin,.,  hi.fore   tlie  .n.l   .a'  th..  lir.t  y.ar  or  Nvi.lm. 
a   i;.\v   v.ars  aft.r  r...i.v.ry   from    t\  nhoi.l   fev.r. 

1    l,ave    n-liahh.   r...-or.ls   i.,H.n    tliis   p.,int  in  Kl  .■as..s  in  whi.'h   a  s,...,ii.ll 
„„a..k  ......unva.     TlMs..  >h,nv  that  in  :;0  ti...  s...-.>n.l   atla.k  ..t   Iyia..M,l  tp .  r 

n-..,l    U.f,re   ,„e   h.pse  .,f  ..n   y..a,s.      In   tW     L".    ea.s    m    Ml^U 
a„a.ks  w......  .r.a,..,l  in  the  (u.n..ral   ll..spi.al,  th..  m>   ryais  were  as  loiln. 

:;;;..  ,„„mi,s  l,,  2  ..as..s  ;  ..ne  year  in  4  ;  ...   v..a,s  n,   'l  :  .hive   years  n,    1  . 
tour  v..i- IS  in  .'.;  tive  v.ars  in  li;   thirty-nme  years  mi. 

'  ",i,   u,e  ease  mwler  ..hs..rva.ion   ii.  whi..h   :'.  attiu^ks  ...■.■iirr...k  the  firs    i 
likewise   ha.l  tWlknvea   in   .^n\rk  <i,..,...s>i.,n.     Th..  pat,..nt  was  a   man,    ..r.^- 
' .v.      v..  ars  okk  « iio   ha.llive,!   in    HamhnP.  fn-n,  the  y..ar  1^.  .,  an.l  .as 
),r.t  s..i«..l  witii  a  s..v..re  attu.k   .-f  .ypli..ia  fever  m_.h..  wm,..r  ..t     M,  ,^  .  S 
an.l  was  at.a,.k..a  tor  .he  s......,..!  time  in  the  year  I.H,i..  '^.t'-'      ' 

i-.„-  ,l,e  mihh.st  of  the  thr.-e  atta.'ks  o. mrre.l   m  th..  }-'''•  '■^■^-      -^.^  '  '   ""^ 
a, at   were  .r..a....l   in   ,i,e  (;..n..ral    llospi.ak    , '"^   .ahiy  ,h,s  pa  i..,,.    ha. 

....„  ha.l  an  a.l.li.i.mal   a.ta.k  .,f  .yphoi  '  fever  m  th..  y.ar     M,,., ;  a.   Last 

W  sla..'.l  thai  i...«as  at  that  time  nn.ler  ,r..ut,nent  m  Alt.,  .a  t.,r  three  week„ 
for   •  u'astri..  fev.r." 

()l,-,.rva.i..n-  "f  th-'  r..i...at...l  .M.,.mT..n....  of  tyi.iw.i.i  f.ver  in  the  same 

in.livi.l  lal  l.av..  h.vii  r..]....!..!  iV.-.n  vari.M.s  H.nr....s.      Th..  Ii>rnr..s  a-.v.. 

i„  .nn.rMl  wi.h  .nv  own.     Thus,  (i...!.  in  Ki.l  has  ,,.....1  two  atta.'ks  ... 

o  ,H.r  ....nt.  ..f  hi-  ..a-..-.  l',.v./ '  in  l.S  p..r  .-.n..,  ami  K.vumll..l. "  ...  •-'•- 

„,,,.,„        A    hi;rh    p..v..n.air,.    i-   n..!..!    l.y    Ki..hh,..-^..'  who    has   pv... 
,.-p...iallv  ...•..•..fnl  ami  .xhaii-tiv..  ...n-i.h....ti..n    t..   the   Mil.......      A.m.nt: 

,;.;.;  ..as^s  ,.f  .vph,.i.l  t;.v..r.  1...  tiam.i  -S_1.2  p..r  ......t.-i,,  wln.h   tw- 

a„a,k-  ha.l  o.-e„n..l.       Al-o.  lu'  ol.-..rv...l  ..,>.•>  in  wl,i.-h  th.r..  ha.l  l.e.„ 
./,,„N.-/,.  .1,vA.  r.  ^'-».  .U../,   IM,  vv.    u    xv,i  ^"-/.   H'l-  ^^^"i- 

•    \\n-/fnr   ^  .li:-liir,    li.l.  iM. 


irrm/jK;  >-. 


69 


llircc  atul  vvvn  fl.iir  :,tt;..-l>>,  a,-  al>u  (iiiiiirkc  '  an.I   C.tli'    1  ca-o  ...cl, 
in    wlrich    llici-c    liad    Ixvii    tlircf   atlai'l<>. 

Will.    ,r:s.m\   u,   tl...   i.ifnsiu-  of  ||„.  ...,.,„hI  an,!,  in  jr,,„,.,„|,  „f  any 

M.l.-....|iMiU    attack    of    typhnM    (rvrr,    tlii>    n.v,l    nut,  a,vnr,|inj;   t y 

.■xiMTi.iMc,  I,..  I..»  than  that  nf  tl„.  H.-st   atta.  k.      ()„  tlu-  <-,,nti-.u-v,  tluTe 

li:i\v   Iktm    aiiiuii-    ,„y  ,,,s,.s   > in  w|,i,.li    tlir  liist    attack    \va>   niil.l, 

^^'"'''   ''"'   -'•" i    ":i^    >'>   xvnv  a>   to   t.niiinatc   fatallv.      Tlii-   i<   iti 

:'<vonl.  on    the  wliolc,  with    the  .■vcrv-.lay  cxiMriciicc   tliat    ivlai.sos   1 

rtHTii,h.Mvn(v>  may  h,.  nioiv  -cv.  '■■  aiul  t.i..iv  proti-art.^i  tliaii  tlic  pri- 
niai-y  attack.  In  this  iv-p.-ct  al>o  thciv  is  a  cciiain  contrast  witli  ilie 
I'cliavior  ,,(■  the  acute  .■xanthcmala,  a-  a  type  of  which  variola  may 
ajriin  he  mcntioMe.j.  [t  i-  kn..\vn  tliat  -econd  attacks  ol'  (hi>  ,li>easc 
arc  aiiMo-t    invariahly    mn.'h    le-s   severe   than    the   (irst  attack. 

Ail  „f  the  f;.rc^r„i„jr  j;„-t^  have  hecn  Icariu,!  from  and  are  ha^.n! 
upon  empiric  oh~crvatinn.  With  inerea-inj;  knoul„lp.  „C  the  vital 
activities  of  the  pathoirei.i(  micro-orir:.ni>ms,  a  I.ett.T  iiisijrht  into  the 
nature  of  inminnity  ha-  I.een  gradually  ol.tainc<l  l.oth  tl..  or..ti.'ally  .and 
-■xpcrin.ent.dly.  Althonirh  rrtain  dclinit..  and  in  .^mic  rcsp.H.f^  e,.,,. 
«'ln~ive  resnits  hav..  I,ec„  rca-'hed  with  iv^rard  to  a  nnml.cr  of  a.'Utc 
M'hvtions   .li-ca^es   (ftamis,   diphtheria),   an.!    whi..h    have   ev,.,    horne 

'"■'""'"  *'■'"■'  '■■"'"  ='  •"■"•'i'''-''  !"'!"<  '■<'  ■  V.  this  asp,H.t  of  the  .|,u.stion 
with  rejrard  to  typhoid  i'ver  is  still  m.Mtth.l.  It  mav  he  ..on>i<Icr,.!  as 
'l«'rn'.nstr:r  d    in   this  .•..m.ecti.m    (K'.  .Stern')   that   the  l.lo.Hi-s,.rnm   of 

.•onvah-cents  fnm,  typi I  (;.ve,  ..ontinne.  „,  possess  for  some  titm-  the 

|'nr«'>ty  of    pn.t,M.tin;r  experinu.ntal   animals.  espe,.iallv  mi.-c,  from   the 

''"''■"■■' ^   '•"••"•'^   "*■    ^^•l''"-i'l    .-Nhnres.       It    has   also    Inrn    po..il,Ie    to 

■M.nnnu/e  animals  t.,  the  a,-tion  „f  th,.  tvphoi.l-l.acillns  l,v  in,.ans  of 
lilten.l  or  i.ntiltcrcd  typhoid  I..M,illon-..,dt,.rcs ;  and  h  has  also  Inrn 
l"">.d  that  tl...  l,lo,Kl-s,.,-nm  of  snch  in,n.,n,i/,.l  anin.als  is  in  tnrn 
lapal.lc  of  immnnizinjr  ,,thc,-   pi-,Kli>po-.Hl   anii.ials. 

Hy  .iieans  of  an  clal.o,-,t,.  .eri..^  of  expe.i...cnt>.  I'lMtfcr  and    Kolle ' 

liave     l>o  .hown  that  the  1,1 !->e.-,n.,  of  typhoid  c.mvalcscents  contains 

Mil.Man.e-  winch,  wImm.  the  scrnn,  in  verv  small  am...ints,  to,r,.t|„,.  „ith 
^'  ;•"'""••■  "*■  the  tvph,,id-l.acilhis,  i>  inj.M.t,,!  into  tl...  al..Iominal   ..avity 
"'   a  ,-,nn..a-piir.  hav..  n.ark,.!  I,a..f..>-i,.i.i.-    ■  .o|K..-ti..s.      Tl......  snlwfan...;s 

ar..    th,.    spc.ific    '•anti-hodics,"    ,.orr...       ,din-    to    thos..   ,|...c.-il«.|    l.v 
I'h'iir.r   in    immni...  ..h,,l...i,-...rn,...       ':  h-y  •  lat..r  sl.,,w„|   that   simil.-.'r 

"'""'-''"'''•'^"  '■''  '»■  I'l'-d"'''--!  in  the  >cnim  .,f  n..rmal  m,..,  I,v  inj.H.t- 


'  /V.'N,7,.  An/,./.  Un,.    M.J.,   H,|     \\\,, 
'  Ih.tvh.  ,,„;/     H,.,/,  .    IMIJ,    N,,,  .17 

"  Ihiitxrl,.  HI,.!.    |(  ,„•/,.,  Nov.  V>,  IHHil, 


'  l„„ii,,   ,),,<..  Kill,  i.Hsi; 
'  Z,,f.f.  II,,.,.,  |!,i    v\i. 


-->     .  "  \\s^ 


70 


■yriioin  ii  vi:i: 


inu  tliciii  witli  ilrad  lv|ili(iiil-liaiilli  mI'  IiIl;!.  vinilciicc.  A  certain  ain.iiiiil 
.if  rcai-linn  \\a-  .•.iii-cil  \>\  lln'  injnlii.n,  rnlluuiii^-  wliidi  llir  -iriii.i 
>li(iuc<l  iiiarkcil    liailciiciilal  ami  a-ulnl  uial  is  c  |ii'(iiprrli(-. 

Similar  iv-iill-  «civ  nlnaimil  \,y  W  v\'J\t  ami  S('iii|ilc.'  liii.li  r  «  Im^' 
(lir.Ttidii  llii-  mclli."!  .it'  |nv\(ini\.-  iii.i.'iilati.in  lia~  In.  ii  |irai-li.ally 
,.lii|il..\..i  III  a  \i'l'\  .■.iii-i.l.ialilf  1  Al.'iil  ill  Imlii  an. I  in  llir  S..111I1 
Alri.'aii  War.  'I'Ih  iv-iilt-  -n  liir  ..lilaiiiol  ap)"  ar  \  1  1;.  |ir.iMii-in;:.  All 
lit'  tli.'-i    rc-iill-    lia\f   -lii.wii    tlial    iminiinil\    in    l\|ili.ii.l    i-    liLi-    llial    in 

el, 1,1,. 1:1 ii    i-  .III.'    Ill    tin     |ir.i.lll.  liiiii    lit'   lia.t.'liri.lal    -iili~tallr.~    ill    tin' 

liliMi.l.  an. I  nut  In  tln'  |)rii.lnri ii m  nl'  anlilnxin-.  At  |ir.-ciii  tin  r.'  i-  11. > 
t\  idcmc  lliat  aiitit.ixii'  >iil»tanr.  -  arc  c\.f  l.iriinil. 


In 


i 


externa:.,  not  individual,  influences. 

Ivocal  Conditions;  Geographic— At  a  lim.'  wli.n  a  -i«>n- 
taiic.111-  li.Ai  Idimicnt  .it'  ty|ilii.iil  fi.ir  \\a--till  In  ii.'Vc.l  in,  ..r.  at  lca~t. 
ul„.|i    ill,.    ii{iiniiin     wa-    hd.l    that     tlic    |irc-iT\  at  imi.    niatnralii.n,    anil 

,li— .■iiiinat' f  the   -|ii.'ili.'  i-niita-iiiin  \\ rr.'  il. 11.11. l.iit    n|i.in    llirrarth 

:mii1    air,    .-li    unal.r    an. I    rvni    ilici-ivc    -iMiiitiram  r     ua~    attacliiil 

til  ihr  liical  .■.iiHlili.iii-.  At  tliat  tiin.'  it  ua-  li.li.vi>.l  that  tli.'  |i.ii-i.n 
ua-   .■.iii-IanlK    iin-.nt.  nn.lrr-uin-'   a    -nrl    "f  -InriiiL;-    ii|i   ami    .■.m-tant 

ri|.iii.liirli.in    in    .Trlaiii    eitii-   ami    .•ntiiv    r.-i.m-.       I'r llii-  |"iiiit  ..I 

vi.w.  Mi-i)iriiiii-  Imil-.-.  -tr.vt-,  l.i.-alili.-.  aii.l  .itic-  uni  -p.ik.ii  ..f.  It 
\\a-  li.'li.N.'.!  tliat  li.'iv  ..i.lv  -.lunil  iiitln.'m-i-  .if  Ma-mi.  trini«Tatiiri-. 
waln-lrvil.  .-|..vially  ,i|'  tli.'  -r.mn.l-wal.  r.  .iftm  in  a  —  iiaatinn  uitli 
nint.ni|Mii-;imuii~  i\.-a\  alinii-  nf  lln'  -"il  :iii.l  th.'  n  m-t  rii.'t  i.m  nf  ~.\\ir-, 
\\.iv  n.v.—arv  in  .ir.l.r  h<  r.fil.r  tli.'  --Iiiiv.l-nii  |Mii-.iii  a<ti\  .•  tlirnii-liiiiit 
tl„.  .■.imninnilv.  At  llir  inv-.  nt  ilay  it  i-  Un.iuii.  .m  tli.-  ..tli.r  liaml.  that 
th.' -.i-.allr.l  l.iral  |.iv.li-!iii-itiiiii  i-  -canTly  .l.|..n.l.nl  n|»in  ih.' .•mi-taiit 
|,r.-.  rvati.in  an.l  ivi.r.i.lil.'liuii  "I'  ih.'  l-oi-nii  in  ivrtain  l.la.i-.  Imt  n|,.in 
the  fa.t  that  .•erlaiii  e.in.liti..ii-.  leini.iprarily  ..r  i..iinaii.ntly  ii.vnliar 
ti.    -ii.'h     |.la.v~.    aiv    .apahle  nf    reii.lerin-    a.'live    t.iiii...iariK ,    ami   nf 

,li-..niiiiatiiit:,    the ta-inni    ari-in-    In.'.illv  fr.mi    tli.'    tvi,li,,i.l    iiatient 

iir   iinp.irteil    fi with.iiil.      'l-.i  he    lak.n    iiit.i   .■.in-i.i.rati.ni    .-|i.vially 

are  .■i.mliti.iii-  that  f  1.  ililat.'  the  .ll^-eiiiiiiatinn  uf  tli.'  l"n-nn  ami  it- 
.•..nvevaii.'.-  t.i  t\ir  hiinian  1mi.1v  thr.in-h  tli.'  ili-.-tive  Iniel.  it  i~ 
iiliviiiu-    fr.iiii     |.ivvi.iii-    e.iiiH.leratiiiii-    that     here    airain     th.'     •.imlilion 

.if    the    wat.'r-i'|>|ily    i>f    a    |il i-    "t'    ntin.i-t     iniiHirtame.       In     tin- 

iiiaii.T  il,..  lel.iii.iii-  helue.n  ihe  -.uli-.iil  .ni.l  the  v, ater--n|i|ily  are  iiatii- 
rallv  uf  imiHirtanee,  ami  frmn  tlii-  jHiint  .il'vi.w  .very  |ihy-i.ian  >ii.iiil<l 

1  /;-,/,   .1/../    ./.-/;■  .  .1mm.  :;n    l>:iT. 


mm 


Eni'l.oav. 


71 


Miakc  hiiM-rlf  tiiniili.ir-  will,  tlic  .■,,n.liii(,ii-  .,f  tli..  -,,il  ;,n.l  ih..  jrn.iin.l- 
ualrr..f;i  placr,  r-|„.,l:,lk  ii,  i|.  rclatiuii-  |,,  tlic  w,  IN  ;,n,l  ,,tl„.r>,,„r>v.-. 
I't'  \sal(  r---ii|i|)l\-. 

lli.ic    have    Imm-11    riiaiU'    in  tlii.,   ci.mK.cti.iii    iimii.-ioiis    valiiahlc   iiivc-iti- 
LMtiori.-   iM.aiiuL:   i'|k,i,    i|„.  ,li||;.,-ciir,..-    i,,    il,,.   |„.rMK.al,ilitv   (if   ilic   <.,il   and 

"I"'"   '!"•    '^'"'i''   =""'    til"  din.,ii,,M    in    « I,   tlu.    .■.|„M-iK<-allv   rontuniinalcl 

-nMiH.I  uMl...-  I.-  r„nv.  V..I.  Nui  |,>,  nNrufr(.ii.s.-tii.li,.s  rWcr  to  llif  ,Mrurmi,v 
nt  I  ir  .h>,.aM-  ni  pla.v.- uli,.|-c  tli,.  ualcr  used  f.,r  driiikin-  and  for  lion-.- 
li'.M  piii-poscs  ua-  denvcd  n<it  fn.ni  «clls,  l,i:t  tVoin  a  distance  tliroii-li  con- 
dinls,  >|,rni->.  and  oiIi.t  walcrwaN.-.  rndcr  Mich  comlilions  tlic  danger  oC 
<'oiitannnaliMM  of  il,,.  wmI.t  wiili  tvphoid-liacilli  durin-  IianMiiis-ion  is  ,.<.«■- 
ciallv  n,  I,,.  cMisid.Tcd  and  invsii^.and.  Il  .-hoiild  parlicularlv  l,c  csiah- 
lislicl  ulirllici-  the  «atcr-Mi|,|,ly  is  convcvcd  tiu-oiit:l,  cndiiils  that  arc 
cvci-vuii,Tr  .-los,.!  and  |,ro|,ct(d  in  L'lvatcr-  ,,r  I, >.,■!■  dc-ivc  a-ain^t  the 
cnti-ancc  ot    torci-n    l.odics.  o,-   i<  d,.i-ivd    from   open  ualcr-conrscs.      In   ij,,. 

';'"''■  "''"'    '111'  '^■'Hilary  ,■ liii f  ,lic   people  dudlnii:   in   proxiniitv  to 

th..  Mivain.  and  the  .■iiMraeier  of  their  industries,  piav  a  rul,'  that  can"  he 
accnratcly  esliinated. 

'"  :i'l'li'i"ii  to  th..  local  pecnliarities  j„,t  des.-rili.^.l,  a  ninnJM.r  <d' 
L-eiiend  condition-  -Ax-r  .d'  -rci  inip,,rtan.-e,  e.p,vialk  the  dcnsiiv  an.l 
the  charaiter  -d'  the  jMipnlalion,  th,.  f.HMJ-npply.  as  ueil  as  other  vJkiI 
and  -pc,aa!  sanitary  cmdition-.  Ai-o.  the  anioniit  and  the  charact(V 
of  the  coiuMierce  are  of  MivMi  inip,.rl  in-'c  uith  r.-aid  to  the  |K,-sil,ilii v 
nfdis-e.niiiation  of  th,.  typhoi.l  p,,iM,n.       In  a  w,,r,|.  th,.r,.  must  I.e  tak-n 

'"'"   '•""-i''«'>':iti,m    a    lar-,.   mirnlH.r   ,d'  vari,,!   nliti,,iis.    i„    ,,.,rt    well 

Nnoun,  in  part  Mill  Imt  iitti,.  inv.stioat,..!  and  with  ,!itii,.Mltv  esiln.at..i 
^"'■"nlin-  t,,  their  iinp,,rta.n.,..  I.ut  wiii,.h  in  all  |H.ssild,.  I.M'al  an.l  tein- 
l""-il  '•oMil.iMati.,n-  ev.rt  a  mark,.,!  inlhan,,..  .\t  th,.  pr..-,.|it  ,lay  th,. 
•linlouy  ,,f  typli,,i,!  f,A,.r  il,  ..,.rtain  pla,.,.-  an,!  I,.,.aliti,.s  ,.,.|nM,,t  !».  as 
•a^ly   aii,l    -yst,i„ati,.ally    lai,|   ,lown    as   ..ippi.^v,!    po--ihh.  at    th,.    ii„u 

^^'"•'i    til,.   oi i<l-wat,.r-tli,.ory    tloiiri-hed. 

_  ll,.w  littl,.  lH.arinu-  hn^ality  it-.^lf  an,l  it-  o,.n,.ral  atin,,-ph,.ri,.  aiuj 
-Innati,.  ,.,,n,liti,,Ms  |,;,v,,  np.,n  th..  .■ti,doLry  ,,f  typl„,i,i  f,.ver  i- .|,.in,..i- 
-trai.d  l>y  th,.  u,.n,.ral  ,ii-tril.uij,,„  ,,f  the  ,|i.,.as,.  ,,v,.r  th,.  ,111:..,.  w,.rl<l, 
^"I'l  tlHivt;,,.,.  in,.lii,|inir  lo,...,|iti,.s  that  (.\hil.it  th,.  nn.st  viol,.i,t  ,.,mtrast 
"Mil  ivuani  t,,  th,.  ,.oi„liii,,n-  nam,.,!  :  typh,,i,l  f,.v,.r  i-  pr,.-,.|it  at  a  ..,..1- 
-i'l-.raM,.    ,l,.viiion    an.l    at    s,.a-l,.v,l,    in    n,,rth,.rii    n.-i,,,,-    and    in    th,- 

"'"!'''-•      ''    "'■-  wh,.r,.v,Tth,.  r,.pr,«lii.ti,m   aiul   dis-,.iniiiati,,ii  ,d'  th,. 

""I""'''"'  ~I""-ili nrairimii  ar,.  not    pi.,.v,.iii,.,|    hy  l,„.al   ,.,,M,liti,,ns  ;  aii-i 

■''"' .-''    ''"-"•  •"■'■   ""-t    varial.l,.   in    ,|,.ir|.„,..  with   th,.  ai,l  ,,f  iinfavor- 

••'''''■•i''''i<l'nts,  tl„.y  app,.ar    ii,,wIk.iv  ,.apar,l,.  ,,f  pr,.vei.lin-  ..iilin.|v  the 
'l<vel,,p„i,ol    an,i    <li-,.,iiiiiali,,n  ,.f  th,.  ,lis,.as,..      Thii-.  it    is  alwavs    an 

""''""'"■'"■  "'■'•'in-,.1 f,,r  th,.  a,lli,  ■■eiits  .,f  th..  Io,.alizatioii-t!i,.,rv' wh;  r. 

III,.  ,ii-,.a-,-    i-    -u.„|,.i,ly  im|H,rt..|    into  a    phnc    pivv  i,,ii-|y    i.umc'.ie,  an.i 


72 


TVi'iiom  I  i:\i:i; 


i\ 


1^ 


I   i 


wllcll  ri.ildil'MM-  t:i\  oi'ill!,''  il-  cli--rliiili;ili(i!;.  ;in<l  |)rc\i(  m~ly,  lit'  CDlir-c, 
iiiil    l;ikcn    inlM    iMii-idiniliMii,    iiliUc   lliciii-cK  i>   :i(li\il_v    iiiiiMiti-I. 

W'itli  iVLTMiil  ["  llir  -|"ri:il  t;f<ij:r:i|iliii'  (li-Ii'ilmlidii  nl'  Ivplini,!  {\-\,\\ 
lllr  Work-  cil'  Miirvlii-oii.  Ilir-rli,'  mikI  uI' (  iri(~-iii;:rr.  wlm  liad  miv  wide 
(•\|iifii'iicc.  t;i\  <■  llic  lic-l  iiit'iiniialiiiii.  Tx  plidid  1('V(  r  |ir(\  ail-  llii'.  iii;li- 
iiiit  Micldlc,  S.iiilicni,  anil  NUrtlii'iii  Kiirii|ic.  'I'lic  di-ca-c  i- ('iicuiiiilcicd 
ill  Sjniii,  ill  'l'in-ivi\ ,  ill  Itaiv  and  ( irci'cc,  in  Nurtiicrii  liii— ia,  and  in 
tlic  Scainlinav  Ian  cilic-.  In  Iviulaml  and  in  a  iiiiinix'i- nl'  iimnlrir- ol' 
I'la^tcrn  l''.iini|ii'  ii  ucciii- ciidrinicalK  in  the  siinc  jilacr- a-  l\|ilin-  ti'Vt  r, 
a  i-irciiin-laiiic  tiiat.  (-|M'rially  in  Miiiilaiid,  |irtvinli'd  ti>r  a  Icniir  lime 
tile  rlinical   ditVcrrli    'iliiHl   111'   I  lir  t  W  ■  i  ili-ra-(-.        N  lllllrri  HI-    lr|iiirl-    lia\r 

lircii  iiiadr  triiin  Nnrlli  Ann  rira.  ( 'riitivil  Aiiirrii'a  and  Suiiili  Annrira. 
t'liiin  Mt\irii,  liia/.ii  and  I'l  in,  I'l'inn  A-ia.  (-|)riially  ('ruin  India  and 
fVoin  tlic  larur  i-land-  ul'  .Ia\a.  Sninaira,  l!"iiii'ii.  ctr.,  a>  In  lln'  mdrinii' 
uriiiiTriiif  and  lriii|ii  .rariU  in.iia-nl  |ir(\  alclici'  nt'  t\  ]iliiiid  li'\  cr.  It 
iia-  iircii  nli-ir\cd  al-ii  in  Atiii'a  a-  tar  a-  (•ominimiratinn  lia-  Ihtii 
f.-Ialili-iii-d,  |iartiriilarl\  ii|Min  tlir  ra-t  and  tlir  \m-I  cua-l,  ainiint:-  lln' 
iialiv  I- a-  Will  a-ainiiiiL:  l'!iirii|H'iin-.  <  irii-— iiii^i  r  Imi'^  aL!'ii  |irii\iii.  in 
fl  Tiianinr  that  iiiii-t  ti  iiAcr  -rr\c  a-  a  nindil  tii|-  -iiniiar  iii\  r-tii:aliiin-, 
tlic   cndfinii-  (u'lnrriini'  nt'  t\|iliiiiil  liver  in    l'",i'\|il. 

Ai)|)ar(iitK  ,  till'  uanii  and  trujiii-al  rniintrit-  d it  dillrr  ;:reatly  i'vuui 

ciild    ri'ui'iii-  uilli    nil  I  rill -I  ■  111  tlir  iircnrrciiri'  and   t'n'i|iii'iiry  nl'  ly|iljiiid 

)'r\i  r.       Miiidfinii-     -i     t\|iliiiiil    ti'Vir    iia\c    I ii    (ili-ri\(d    <  \  rii     ii|hiii 

liiLih  iiiiiiintain-,  ill  ]>lai-t-  nmrr  tliaii  Idnii  niclcr-  iiii;li.  Tlir  ciiidriiiir 
iiiiiin  till'  L:rial  St.  r>iTiiard  and  in  the  vallfv-  radiatiiii;  Irmii  it.  al-n 
cited  li\-  <  Iric— intref,  i- "ell  kniiwii.  At  that  time  iinc-tiiird  nl' all  nl' tlie 
inoi;L-  in  tlie  inniia-tery  at  that   |ilaee  were  attaeked. 

Ajiarl  rrmii  the  ahililv  of  the  ty|ihiiid-liaeiihi-  tn  lieennu'  ludired  and 
dcvelii|)  ill  aiiv  liiealiiv,  and  it-  imt  iiicnii-idi'ialile  tenacity,  tlie  uidi^ 
di-trilintimi  "f  tli''  di-ca-i'  deiieiid-  liirthcr  n|)iiii  the  aiii>aienll\  eijiial 
-ii-ee|ililiilitv  uf  all  race-  tu  it.  In  tlii-  l'c;:ard  al-o  typhnid  li'Vcr 
eshiliit-  a  e(ilitr:i-t  with  ntllef  inl'eiliull-  di-ea-e-,  -ince  to  tlie-e  there 
ai'e   marked    variaticms    in    racial    -n-ce|itiliilit\ . 

It  -hiiiilil  he  nieiitiiiiicil  ;iat  |icr-Mii-  vvlm  have  recently  rcnuivcd 
til  a  -ii-ealled  tv|ihiiiil  lucality  nr  hav  ■  n-iiled  in  -iicli  a  |i!aee  Imt  fur  a 
-hurt  lime  arc,  a-  nnmcrnn-  uli-crv  atimi-  have  -huun.  attacked  with 
c-|iecial  reidiiic— .  Such  i.Ii-cia  aiimi-  ha\.'  he.ii  ni.ide  in  I'ari-  and 
l.iindiiii  l.v  Liiiii-.  <  'hiiniil,  .Iciiiier.  .-ind  Miirchi-uii.  The  p  iy-)ciaii-  nt 
X'ieiina.  and  e-|iceiall\  tlm-e  ut  Miini.h.  iia\e  had  a  -imilar  e\|iericiiec. 
.\ii  e\|ilaliatii>ii  liir  tlic-e  midniilited  liict-  i-  a-  yd  walltill^^       I'liniicrly, 

'  7/,>r  ./ //■,  l',it/i. 


X 


,««■•. 


i:r/ni.< )(,)-, 


73 


a    -..rl    „t    ••M,',li,n:,fi/ali,„i"    «m-  oiriui,,!    rnii-i,|,.,,.|   a-  a   prnpliv  larti,- 
a-aii.M    III.'  .li-,,,-,.      As    iin-.ii|,|H,ri,.,l    a-    llii-   a-inM|,.ioi,    |,a~    aluav- 

'"■'■'';   ''   '"'-  '" ""■  'lltiivly   liMIriial.lr    ii,    lli,.  |ii,|,t  ,,|-   ,,T,„t    | u  I,.,!.,.. 

^''"■'""-'' ''''""-  '"'I-'    !"•  taken  iiit.,c,,M-i,|,Taliuii  in   tlir  rxplaiiatinii. 

Ill    III.,  lir-t    |,lar,.,  il„.    ,„.„.  iinii-iial    iii.hI,.  ,,f  |ii;.  i;„.  ,„,„,. .,.,,  ,,f,,,„ 

.lilHriiiir    ;.rivall.v     In.Mi     ,|„.    ,.ivvi.,n-     i,„„|,.    ,,f    IJH,    ;,,mI    -.,    iu'v^nu.^ 

ill,'    .h-r-livr    ,li-,,|-,.-     |,|V.|1~|M.H||M-     „,     t\|,|loi,j     il|t;.rli,,M.     i-     uf     i|,llM,r- 

'■""''•       '"    ''"■    '"■^'    I'l'"'-'-    i'    -I    !"■    I">nic-    ill    iiiiiiil    that    til,,   ii.'n- 

'■•'UUV      i~      ill      y,,,,,,,-     ,1,..,,,,,      ,.,,„,„„|       „,      ,|„.      ,|.,„^,.,.      ,,,■      ,,^|^j_^^^      ^^^^ 

''"■  I'"'-""-  I"''"'"-'',  niililvr  ill,,  naliv,-,  l„.  ha,  nnt  |„,,i  lau-lit  l,_v 
-A|.rri,.,i,-..  aL-ai.iM  partakiii- uf  .laii^^rrMU-  lliin^x  |„  tin-  ,.,„i,i,.,-t!,,„ 
llii"l!inkiiin-watrraii.l  ailirl,-  ,,|-  t;.,,,!,,,,,,  i,,  tl...  n,M-,H,k,.|  -tatc  arc 
t(.  Im'  ii„.,iti,MM..|— in  -ninlinn  ■  ,,uiiiri,.,,  i;,r  in-ian.v.  rau  iViiil.  o\ -iriv 
•■I'l.l  ,.lii,.r-lirll-li,|,.  ■r,„,|i,,l,,  ini|„,rtan,,.-liMnl.l  n,.i  l„  .i.tarli,.!  to  tlic 
'■ir-niiiMan.T  llial  aiimnir  ,|„,  n,.u,-,,ni.T-  tlinv  v  ill  !„■  nianv  with  a 
mark,,!  |„.|-.on.,l  |,rnli-,„,-iti,,ii.  With  ivi^anl  t.,  tran-imrv  rr-Mnicr  .,'i- 
'"'■'■'•■'"■  '"  l"r"l'i'i"ii  ill  a  |.la  .  Ii,  illliv,  voun-  an,!  aclnlrMciii  (.nvoii-.. 
ti-.iv,. I Iriv.    „i,.rl,ani,-.    lalu,,-,.,-..  -,.rvant-.  ,.t,..,  aiv    ,.-|.,..-iallv  .•,.ii,.,.ni,.,|." 

■■  A,-,'liinati/,ali,m-,li-..a-,.-"an.,,tt,.n-,M,k,.,i,,r,  |,ar.i,.,ila'rlv,|iaiTli,.a: 
l.y  «l,i,.li  n,.u,.„„„.r-  in  a  ty,.|i,,i,|  pja,,.  aiv  atla,-k,.,l.      It  i,  n,',,  in,,,r,,l,- 
aM.'ilial   tli,-,.aiv  ,,tl,.|i  ,l,.|M.n,|,iil   iipm,  tvpihii.!  iiif;.,.ti,,ii. 
'W.,..o;-    T.phunl    Frr.r    r.rrnr.l    n,l„    .l,„;,/,<.<j.f„/.  of    l.ri/..;,;   fn,n,    ISSn  U, 


Yt  111.        I^,'!.      IsM       ] 


V.J      I--.;      ;ss,      ,,.,     „^,,     „.;      „,,      ,,,,,      ,^,„      ,^,,_      _^,,^    ^.  ^^^^ 


■  I:, II  ■>  In  IJ  ,;  I-.  ..|  ,,  .,  ., 

y-'Tl'         ■•         -       I-'         ■-.       I::       II  I       ],,         I 

-\|"''i  ■'■        ■-        •-■       111       i;.       III        - 


In       111        :,        'I       |-.-> 
s       14         .-,        .,- 


Miiv  II 

•lull'.  .".       In         .;         s 

•liilv  ,;       17         ,,       .J, 


^     ':,    ','     .!     1     ■'     '     ■■•■     '•     »     :i 

■^-    ^'  '^  "1  i'^  ..  "'  n  !;   :  ]::  \',  i^   ::  .■■:;; 

■^'1''         -'     -'•'      I"     -"      T'       'I      1 1,      r,       4      .■     •".!■       ■      , 


I),. 


»     1     t     1    1 


1 


n 


III        I  I 


II        in        17        l; 


.11 


Season  snd  Meteorologic  Conditions— Tv,i|i,,i,l  iW^v  .x- 

' '-•"•""■^'•■i"t  ami  rnri,iany,-,,uiitrii.-aMiiii;,r.iiivlati,,n  t..  il„.  M.a~,„i- 

.1"'"  ''" '"'"'"'  "'■   '■:'■'■"!'-■.  i'l   Kii^lan,!.  aii,l    in  ,.,a,nlri,.~  |in-..,itin.r 

-mnlar    ...m,l,ti,„„.    a-,    tiir   inMamr,    Nmtli    Ani.ri.-a    (  Ilartl-tt.    \V,«mI. 
'■'"">.  lliin    ,>,vva,l~.  M,  i;.,r  a^  ,v,„.-n  .^„.  ivniarkalil..  nnaniinitv  in  ,l,i< 

'''■-•■"■''■       '•:v<'>-.vuli,.r..    ,|„.    in,T.a-..,|    IV ,„.v    ,„.,.,„•-    .Inrin-  'tli,.    latr 

HUnni,..-  an,!  aiitiinin ,||..       [„  ,..,„.,.ia||v  .,.,,.,-,.  an,!  «  i.l,.,,,r,.a.i  ,.,,i- 

'l'-"'i<'>    it    iMi-Msts   ,,i    in,r,a-.-   ,.v,.n    Int..    tli,.   uim,.,-.  niilil    \„v,.ii,l,,.,. 


74 


%yrnnn>  ir.vin 


:ni(l  Dr.viulMT.  Kn.Mi  llil-  liin.'  lliciv  i-  ;iliMn-l  :i1\v:in>  a  «lnw  ur  a  mciv 
,.,,|,j,l  ,l,,,.li,„,  Hu.  ,„.ri,Ml  ,,ri,.a-t  |.nAal,nrroflvpli.>i.l  Hvrr  i-  (•v.rv- 
wliri,  iIh  -prill;:  aii.l  ihr  iM-inuiiiu  nf  -miiin.r.  r-|Mvially  tli.'  iii..im1is 
(,l    Manli.  Ajiril.  ami    May. 

In  l,.ii>Hr.  a-  llir  ar,oin|iaiiviiiL'  .lia-rainiiiatir  ni.nsfiilatioii  of  llic 
,.,.,.-  .,1,-,.|v.mI  in  llir  .la.-..l..->|.ilar  l.,lur.-ii  \W  yia,->  l^Ml  aii.l  l>'.f-'  -linu>. 
,|„.  innnili-  in  uiiirl,  lla-  lai-vM  hun,l,.r  of  ,aM  -  ..r.nnv.l  Wfiv  uuan- 
.,1,U  \a-uM  Sr|,|rnilMr.  an,l  (l.|,.l„.r.  Nnv.ail.rr  al>n  rNliil.it.,!  m,  l  hr 
■  ivrri".'  Iii'l.  ll-niv-.  •nu'lu«,>l  |.iv\al.'U.cin  1  .ri|.>ic  n,vui>  in  ll,.' nimitlis 
or  \l.ril  Mav,  an. I  .lunr.  In  .Inlv  llu-  iarria.-.-.  imurv.r,  -.-luTallv  l..'L'iiis 
i,.r:„n  an.l  il  mnlinu.-.-  uninw  i  i-u|.l.  .IU  l-  il>  a.anc  .lurin-  llir  auluinn 
iimnlli-  (  Ki"  *  .  A  laMr  >liouih_'  llif  nunil.n- cf  raM>  r.-cav.-d  diinn-  llif 
.lilf.r.ul  inonlli^  an.l  s.ai-i-  a.l.lr.l.  Tlii-  i-  .-M  ivnuly  inl.n  Min-  tn.m 
II,,'  ■■viua-al  unifnrinilv  in  liir  rnn.iiii..n>  .liini.L;  llif  dillcrrnt  y,-;u>.  AIm> 
in  I»i-.-,U.|i.  a.v.n-.linL'  m  lla'  ..!.>,  r\  alinns  nf  ricldrr,'  .•xl.'n.lini.'  nv.T 
,.l.vn    v.ar*.   tl,r    iiP.i.ll,-   -f    A|.ril    and    Mav    .xliil.it    llu-    UaM    livqiuaicy 

,,f  ,v|,l,;.i.l    Irv.i-,    ul,ilr    Au-uM    :   >,-yU^uW-v   ,-l.nu    il„.    In-lu^M    wlnlr   a 

.M-.ai'r  nnnd..i-  ::r,uTalU  ..r,nr  ,n  ll,.«inl.r  n:..nl!,>  lliai.  in  .Inn-  and 
lulv  V  -ii-ikin-  ^ilnilariIv  h.  iIi.m-  oI.m  i-,  aii..ii-  i.  .■xlnlntcd  Ky  lli-  cyn- 
.lini.iKin  I...i,dunasd.Ma-il.;dl.v  Mnnin...ii  im- ilu-  adnn^-ion>  lo  lli-  L..ii.  nn 
Frvca-  ll...-i.iial  l.iuwrn  iIm-  yars  1^4^  an.l  1  >l.-'.  I  l.av-  !;'''l;;'''''\\''^ '',';'; 
"ram   <.n   tlif    La^i- "I'  lii-  slaleinent.-  ■  1' ii:.    ■  ' ""  ~   ' "  "" 


In    iI^   dftaiU   tin'    Lnialdii 


Hii^^mn 

'lOn 
MM) 

■  I 

- 

-- 

-  - 

i 

- 

.\f)n 

^:v.ii 
ajo 
anil 

J  HO 

. . 

- 

~ 

- 

f 

/.   .  il 

J    4 

1 

iJtSO 

- 

]V 

l-"tO 

'aL'o 

t 

- 

MO 

1  mo 

1  Kill 

;  1  w 

I  120 
1  100 

i 

\ 

- 

- 

1 

i- 

- 

■  no 

; 

V 

'   '    ! 

~^ 

.lia.M-arn  a.  .•nmnarr.l  uilh  llial  «\'  l.-ip-i''  .■xliii'it.-  a  r-dnnioii  in  tr.- 
MnwHV.luiiin-Mlu.  uinirr  iu.,nll,-  tVon,  ihr  maviniiMi.  of  tl,..  an.nnni  nmnt  i.. 
airhorrdilla'nnnd.ri-i>-lill.|uilclapj.Mluriirjll,rinonlliot  I  IcTinlH-r.  1  lii> 
n.jalion  ai.i-ar-  1..  rxiM  .-si.iMiallv  in  llinsr  |.la.v>.  and  alinn>i  ..v-ryvv  lar.. 
In  tl„,.,.  vars,  in  vNJii.li  llu'  a.-Tnt  nf  thr  rurv.^  l..-ins  >-.,n.«  hat  lafr  and 
,|„.  niaxin..  :  i-  ivarlu-l  ,-„riv-,..ndindv  lal.r  .in  I.aidon  >r\A.u)U^r 
.,,,,1    (»,.|.,l,..r.    a.    .■nini.aiv.l    uilli    Aiil'IiM    in    l-ripMr..       1  !,.■    -i.idnnn-    ol 


W^^^-^^^^mmf^^'^'Wrnf^  ^W^W¥^ 


ETIOI.OCY. 


76 


ISStJ^MT  in   Hi 


iiiliiirL''  IS  iiistniclivc  in   lliis  crinMcctinii,  \\w  t:\\'\i\ 


I'lu  iricrca.-r  iii 


Ilif   ilisi'ii.-c    iM'ciirriiiL'   iliiriiiL'    llic    intintlis   nf  S.|iI('Iii1mt   ami    OriuKcr.  and 

ind    .hupiarv    r\liiliilinLr 


aci-iii-(|in:jl\'    iIm     niiiiitiis   dt'   N 


•  \  I'nilicr.   1  'iM'cnilicr, 


Uii'    nia.xujiiini    prcx  aliin 


j-JL'.  •; 


lll&5  4  5ri.^i| 

ihM^nm 

375 

i_; 

1 

1 

■   '      I'll! 

' 

1 

,f\ 

^  i  ]  1  !  rr+-> 

~ 

[335 

- 

U  1  i' 

— n- 

.lOO 
■;i75 
:2r>o 

2Tj 

\ 

1  1 

/ 

-^ 

~| 

is_ 

f\ 

r 

i 

JXT 

FF 

'  ■  1 

f 

— 

1 

-4-!/i 

JCIO 

•" 

1 

\ 

rn/i 

1 

1  '  ' 

\ 

L 

1  JTi 

\I^ 

~ 

/ 

\ 

^  /I  1 

...  j 

/ 

l\ 

7 1  I 

ion 
75 

N 

i 

r 

^       i 

/ 

1 

... 

k 

_.. 

□N^t/T 

1 

v\  :  :  y 

"^  ;  ! 

\ 

/ 

!     1 

S/^^^"^ 

^y 

- 

t) 

'I'l 


If  I'au-r-   l(i|-  III 


i-  riinari^aiilr  nniiiinnily  in  llic  ri'lalimw  nl' l\  iiiidid 


('   nnivnsaiitv  nf  il 


tr\iT   In    ~ca~uii    arc  a-   yet    wholly    nnkiiown.      '!"! 

ivlaiion,  it-  rcciinvncr  in  all  |MP~-.il>lr,  rmintcly -iiuati'il  rciriiHK,  iiidi 

that  it  !■-  c|r|icnc|cnl  ikiI  n|ii>n  lucal,  lint  n|Min  urncf 


-iirli   a-   ai'i'    fi--|iiin-il)lr   i'liy  ll 


il  I'cinditiiiii^.  |i(i«~lldv 
■!•  "I'  iiiiihi|>li('ation    and    the    \  iial 


■tivity   <,\'   the   lyplioid   urrni    it-,lf.      Alii -h    imirh    i~    I 


kiiipwn    witli 


iv;;afd    td  the  detail-  in    tl 


IIS  ninncctiiiii.  an    ni-i 


-ht    ill'.,  tl 


If   --ohitiiin  nf 


liciicral    i|Mc<ti(iii-   i-   wanliin:',  jiarticiilarlyllK'    iiialinii  i.C  |||. 
ini|Hirtanl   (■(..-niic  < litiniH.      It    i-,  thiTrtnrc.  I 


II'     |liil>on    In 


inter  Inr  the  ja-c-int    t 
a   Lilariiiir  dcticiciiiy   rather  than    tn   iiriduv   it  nver  witli   iiii.-talil 


tlleiirie' 


W  ith   relatiiiii   to  the   iiifliieiiee   iif  weather  anil 

h  d 


tenilier;lllire    in    till 


lert     I-    iniieli   diver-itv   nt    iipmi 


iti(ilii!.ry   lit"  ty|ihiiid    fever   tli 

\M'iler>,     .111(1     there     exists     I 

>ea.-cin.      Ill    my  <i|iiiii<iii    theri-   are   im  lixed    1; 


|imiiiii   aniiiii;. 
ly    ii'i    mean-    iinaniniit\     with    .I'l^ard     ti 

r<l.       'i"n. 


nv-  111    till-    reu-ii 


llllleli   Mil 


IKirtaiiee  has  eertainly  been  aitaehrd  td  i.-dlal<d  ini|ire--idii-  and 
dl>-ervatidiis  in  -dine  endemi<-,  and  |ireiiialiire  >:eiienili/alidn-  have  lieeii 


de.        Il 


I   L'^c'iiei-al.  It    ina\' 


.1  tl 


le  said  tlial  in  iiin-t    Idealities  sin 


imer  heat 


and  dryness  render  |irdiialile  an  iiierea-e  nf  ly|iliiiid  fever  in  the  aiitiiiiin 
III,, nth- — an   oli-ervatidn  that  is  in  aeeonl  with   the  the-irv  nt'  I'.iihl  and 


I'etleiikdfer  and    led 


lip  Id  the   ^Tdiind-water   t! 


vv. 


M"het! 


ler  iiaiiiji- 


ne>s  aiK 


1  cdid  weather  dpei-ate  in  an    n|)|Ki-ite  d 


irc-tidii  IS   -till   ddiilittii 


iretiil    nioervers.  (Ill    the  (itlier   hand,  have  attein|ite(I    to  altriiiiite   the 
■veldjiineiit    and    the    iiierca.-c   of  the    dise;i-e    in    sdiiie    |i|ueos   to  tl-e?:*! 


7« 


rvfiiDih  I  i:vi:n. 


If 


'A  ! 


lallir  ((.nilitioii-.  A-  :i  in:illii'  <>(  i.uU  it  i-  nailily  c-oiicrivMlpIr  lliMt  tlic 
\iru-  iHvidciilailv  di  po-ilcl  m|imii  llic  -iiirarc  d'  llit-  .arlli  or  in  iIk 
ii|i|Hr  la\.r-  ><{'  ilic  -"il  may  Im  carrifil  ■•IV  li\  I'ain-ualii-  nr  nirliini;' 
-n,,\\.  and  Im  ili~-(aniiiati(l  i>y  linilinu  it-  "a\  inln  wah  i-<  ondnil-  <ir 
urll-. 

Occurrence  of  the  Disease  in  General. — Sporadic  Cases ; 
Endemics    and    Kpidemics. — Aliir    liavin-    coii-idcivd    ilic    ciidlo^ic 

ivlali'iii-  ill  d.lail.  and  lja\  inu  pn-rntcd  an  c -innn-  ma— nl'  individual 

(AiH'ricnii- anil  linl-.  a  I'lW  «o|-d-  witli  ici:ai'<l  t"  tin' iirm  tmI  cliai'artrr  ol 
the  di-ra-r  and    il-  uiini';il    nianifi-talion-  w  ill    Im    :i|ipr.i|iiialr.       Iiillii- 
inimcriinn    al-o    niai'krd    ditVcivncc-     tVnm    (.tlirr    iiifrctidU-   di-ca-c-   arc 
a|i|>ai-cnl.  (-[Hiially    tVtim  lln'  acnic   lAanllicmata.    |iarlirnlarly  tlir    inic 

l„.,lil,,ii,., mall-|"i\,  l\  |ilni~  fever,  elmlera.  ami  plai^iie.      A-  lia-  lieeii 

mentioned,  llie-eare  Liinei'ally  eiinlin.ed    to  deHniii^  (".rlion-nl'  the  earth 

and    to  certain    c.nmlrie-    in  which,  like  a  tire   - nlderiiiL'   l.eneath    the 

a-he-,  ihev  (Mcnr  inn-Iantlv.  Iin!  within  iiairow  limit-,  and  then.  Ii'oiii 
lime  til  time  llarinu'  np.  they  (Mend  over  preal  di-tance-  and  area-, 
'rill'    pe-lileiice-  iucludcil    in  1 1  !.■  aciite  e\an I heiiiata — v.iri..l.i  and  typhn- 

tixcr arc  al-i.  little  <lepeiidcnl   npnii  the  >ea-iiii  of  the  year  nr  upon  the 

:,„■,..  'I'xphnid  liver,  a-  h:i-  Keen  -ecu.  i-,  mi  the  cdnlrary.  di-lriliiilol 
uv<r  the  entire  wnrld.  lieiinr  rather  dependent  upon  the  individual  and 
the  aciivitv  I.I'  hmiian  intcrcniif-c.  it  alnm-I  never  di-appear-  in  pupn- 
jiiii-  eiiic-.  while  ill  the  ciiiiiiti-y  it  is  ircneiiilly  ali-eiit  nr  ncciir,-.  Imt 
iH'ca>iiiiially. 

Ill    t'lirtlier    ciiiitra-t     with    the     c\anthematiiii-     infei'tiiuis    di-ea-e-, 
tvphiiid   I'ever  ceiierally  iMciir-   in   -|Mif.idie  ca-e-  nr  in  ^rnii|i>  xi'  ca-e>. 

nirinc-    in    dwdliiic-    a-    limi-e-epidemio,   m-    ncea-iniially    ^preadiiitr 

thrnii-hniit  entire  -treet-,  if  the  eniiditiuii-  fnr  ciiiivi  villi;  the  intlvtiiii;- 
a-eiit   arc  aceidiiitally    thus   iinitiirinly   di-tril>iile<l.      Wy  the  jii\ta|Mi-i- 

tlmi    nf   -neh    di-ca-e-fnci,  nr    le-s    eninninlllv   llnin    the   nllt-et,  nU  ill^'    In 

iiin-t  liiviinilile  mmle-  nf  di— ciniiiat inn — watcr-eniidnit-.  stream actual 

epidcaie  di-triliiilimi  nf  the  di-ea-e  may  iv-nlt.  In  im  iiiMaiice,  Imw- 
cver,  line-  rapid  di-cininatinii  In  iieii;lilMiriliir  cnuiitric-  nr  thrniiclmnt 
the  elilire  Wnrld  take  place  '.•nm  -licll  a  fncll-  even  thnllMli  it  i-  nf  enf- 
-idiralile  nr  nl'  latere  -i/c.  a-  i-  the  fulc  with  lyiiliu-  fcver,  elinlera,  and 
pla;:iic.  'rxphnid  fever  a!wa\-  iiiaint.ain-  a  tendency  tn  Incal  limitatinii, 
and  thi-^  may  he  altered  mily  liy  >p.vial  cniidiliniis.  Tin-  t.ndeiicy  can 
he  readiiv  e\plaii!eil  ;  it  i-  a  ncec-ary  n-iilt  nf  certain  characteristic-  nt 
i;  tvphniil  ccrm.  which,  a-  ha-  heeii  -ecu.  i-  imt  .a-ily  traii>mittcd. 
lint    niilv  ••\ccptiniiallv    i-   carried    tlifniitili    the   air,    and    then    mily    im' 

.1     ..    .   .   ,....l..    I...:.,,,.    .....,.'    tli..    i,.n:..iit      \<illi.i:it    enlllMct      i- 


:w^^  W^P-^ 


i: I  I'll. ')(,)■. 


77 


live   trmii  (laiiijir  f..|-   .acii  liiijlilx    |ir.ili-|"i-cl    |i.i-nn>.      (  )iil\    l,\   din-.t 

•  Mincvailc.'   of    lllr    |...i- r   coliVcMIIM'.-     lllf(.llijll     lllr     illll'nilc<li.llir,ll    nf 

.1    lliliil    |pci-ori,   :iii>l    llii'ii    ..iil\     liy    uay    nf  llii'    dij^i-livr    liact,    i-    lli.' 
ili-ra-i-  Iraii-iiiilh  il.       All   ol    llii-flart~    \\<it  lun-- ai^M  ;:i\  i  n  i  \|.fi  — imi 

In    ill    ihr   .inillM-lancc     llial      l\|llloi>l     fever    wa-     lir>I      illelllileil    arm. II-    tile 

"  e,,iiiai;i(iii»  "  <li-ea-i-,  lull   iceeKed    ilii'   i le-i:;iial ii .n-  "  iiiia-iiial ie  "  aiiij 

"  edlltai^ioll-.     lllia-lllal  ie."     W  llieh,     aeeiirdilli:     U<     e\i-lill;;      \ie\\-,     are     III! 

|Miii;(  r   |i(rmi>-ilile. 


CONCLUSIONS. 

'I'lie  |1  liLTiiiiiir  eeh-ideralioii-  lia\e.  il  i-  liMjied.  -Iinuri  that  tlie  eli.ilii;;v 
lit  l\|illi.id  level'  a|>|iear-  at  the  |ire-eiil  day  in  (|iiile  ditlerellt  lielif 
fnnii  that  III  uhieli  ii  \\a-  \le\\ed  in  preliaelerioio^ie  time-.  Il  will  lie 
ii>efiil  til  -iihiiiiari/e  w  liMt  lia~  tliiH  t;ir  Imcii  rendered  eertaiii  or  |priilialile. 

')  lie  de\elii|)nieiii  and  tlir  maiiile-talinii-  ut'  t\  |ilinid  te\  er  are  de|ien- 
deiit  ii|iiiii  the  le-imi-  ill  the  hmiiaii  nrt^-tmi-ni  n-iiltin'j- tVoin  the  inva-iun 
:iiiil  the  vital  aiti\ily  <.f  the  KI)erili-(  Jatlky  l.aeiilii-.  The  tv|ihiiii|- 
liaeillii>  i-  not  ideiilieal  with  llaeiljiw  euli.  The  relation-  that  e\i-t 
lietwii'ii  the  two  iiiiero-orijaiii~iii>.  and  their  lieirree  of  relalion>hi|i,  iiin-t 
l>e  e-tahli-lied  liy  further  iiivc-tiL:;iliiin-.  'I'lie  ltovmIi  .-iiid  the  de\elo|i- 
ineiit  of  the  ty|)hoid-l>aeilhi-  take  |)laec  exehi-ively  in  the  ImmIv  ot'  the 
typhoid  patient.  The  nerin-  are  thrown  otV  e-peeialK  w  ith  the  iiiti-tinal 
<!i-eliar<re-  and  urine  of  the  -iek.  and  eive  ri-e  to  new  ea-e-  of  the  di-ea-e 
principally  hy  crainiiiu'^  eiitraiwe  in  a  viai)le  eondiiion  tliioiiLih  the  inuiith 
ami  the -toin.ieh  iiitu  the  inte-tiiial  tract  ol' |)!(di-|)ii-e<l  individual-.  The 
entrance  of  the  virn>  tiiroiii.di  the  aii-|)a"aee-  cannot  he  whojlv  exchideil, 
l>nt  it  i-  ill  ircmral  uf -iihordinate  iinportaiU'c  It  i-  liir  tlii- ri  a-on  that 
mere  prc-eiice  in  the  vicinity  of  the  patient.  Muh  a-  -nlliec-  fi.r  intectiini 
with  the  acute  eNantlieiiiata,  i-  not  adet|nate  tor  intiction  of  even  tin- 
most    predi-po-ed    individual    in    the  ca-c  of  tvphoid  fever. 

Pvphoid  fe\trdi«--  not  liclun;;-  to  the  '•  <'ontai;ioii- "  di-ea<c-  in  the 
older  siirniticanec  of  the  term.  The  typhoid  virus  i-convexcd  directlv 
fn.ni   the    patient   and    hi-   dejections   or   tliroiii;h    hon-eliold-arliclc-  and 

healthy    third    per-on niir-c-,    attendant-,    etc.  ;   or    liv    rea-oii    of   its 

inarkc<l  tenacity  it  remains,  under  the  most  varied  e\teriial  conditions, 
attached  to  varioii-  media  and  tor  a  loiiir  lime,  in  a  state  of  vitalitv,  in 
order  later  to  irain  entrance  into  the  hiinian  heiiiir.  <lirectl\  or  indirectlv. 
Ivphoid  fever  may  lie  coin  eyed  fur  ereat  distance-  l>v  mean-  of  the 
-ick  tlieiiiselves  or  liy  eerm-laden  media.  The  lielief  that  tlic  hacilliis 
alter  leaviiie;  the  liody  re(|iiires  further  dev<|(ipiiieiit  and  matnralioii 
oiit-ide   the    hody    i-    imtenalile    in    the   present    state  of  kiiowledire. 


T)  rii'iiii  II  \  1 1:. 


'M 


'I'lic  i)|-iiiri|i:il  cirri. r    :iiicl  .li-c  iiiiii;i|.  .r  ..t'  ili,.  t\  pliMhl  -mil   i-  u;il.  r. 

1)1— ,iiiiii:ili I'  llir  l,\  I'liniil  -.rill   ill  ihc  .Irv  -lull',  :ilMiliril  I''  |  i;i  rl  i.l( - 

..r  ilii-l,  ihroii-li   ill.    ;iir   i-    |i..--ilil.'   I. Ill    nil. ■..111111. .11.      'I'lic  ..|iiiiii.ii  lur- 
, I, ,.,.!,    |„|.l  ili;i|   i\|.li..i.l    r..\.r  iv-nit-    IV.. Ml  ill.'  -u;ill..\\iM-   ..r  iiili:il:irh.n 

«ilii]il\    .if    |.iilrl.l    l:  1-.-    Ii:i-    l.r.n   uli..||\    :iii:ili.| 'l.        I  t.|...-ili  .1    ill    llic 

,.iilli,  llic  l\  pi.. .1.1  .jiiiii  111  i\  r.  iiiaiii  .:i|.;ililr  ..I'  .l..\  cl.  i|.iii.  iil  lor  :i  liiiic, 
(,,  |„  .|,|-,.:i.|  rr..iu  llii-  |H.iiil  llir..i|.jli  \:iri..ii-  ;icii(l(iil:il  clih  Iil  I..11-, 
Mill. .11-  ulii.'li  .iilr.Mi.-.  liil..  -iil.-.'il-u;il.  r,  u.ll-u;ilc  r.  ..r  |!..\mii-  \\:ilrr 
],1:!\-  ill.  in..-t  iiN|...rl ml  i.,iil.  A  l..."il  |irr.li-|...-ili. .11  in  llic  mii-.' ..I 
,-,,,i-i  ml  iiii|.i-.  •jiiiili.iii  ..r  ill.-  iiirtli  in  ;i  -i\.ii  I...Mlil\  \\iili  iIk'  |>".i-"ii 
:i:i,|   iii;iiiir;ili..li   lli.  r.  in  .11111. 'I    I"'  :i.i-.|.l.'.l.  :iii.l   -lill    Ir-  llir  |>illilnili..n 

c.r  ill.    |...i-..ii   iiil^.  ill.    ■_!■ i-:iil'  :ili.|   iiil.  .li..!!  ..r  llic  lifi-lil".riiiL;   |»'..|.lc 

|.\    ..siril  ili.m-  rr..iii  lli.-  <■  ill  n. 

Til..  -ii-.-.|.lil.ilil\  I'.  t\|.li..i.l  ll\.i  i-  .A.r,..lin-I\  \\i.l.-|.n..iii.  N.) 
I;,,,.  1-  .A. nil. I  nv.  -..  till-  :i-  .  \|..Ti.ii..'  I.M.Ii.'-.  lil;.|.li  ill\  1.—  |.iv.li-- 
.„,„.,|  T\|.li.'i.l  t'.Ml'  li:i-  I'""  ..l.-.r\c.l  in  :ill  .ivili/..!  c  .iiiil  lii-  ..f 
ll„.  ,  irlli.  in  ll..  ni..-l  \;iri.-.l  .•liniiil.-  :in.l  :illiliiil. -.  ^'..1111-  |irl>..ns 
:iii.|  .1,1. ,1, -.•.111-  |.riii.i|.:illy  ;iir  |.iv.li-|".-..l  I"  lln'  ili-.M-.',  :iiiil  rni.li-t 
Mii.l  u.ll-.l.\.l..p,.l  in.li\  i.liril-  III  -.11.  ral  111.  iv  -..  llriii  llif  «.:iU  :in.l 
tli..-.  .l.'l.ilil  I.- I  l.\  lii-ii-.'.  ('liiMr.n  nil. Ill-  llir  :ior  ..f  ..nr  yv.iv  arc 
:ill;i.!..'.l  uilli   ,Aliv r:iril.v.       All.r   lli.'    r..i'li.tli    v,-:ir..r   liH'   llir    tV.- 


..n.n.'V  .l.'.'llii.-  I'.ii.i.llv.      S\  in  il-.lf  lia-  n..  niiirU.il  11 


llllclicc.       1'..— i- 


i.K    III, 11.  in  ,...ii-,'.|ii,'n,','  ,.)■  -..,ial  an,l   ..llu  r lili.'ii-  ..f  iil-'.  aiv  iii.'r,' 

-nallv  |.\|..,-nl    I..    iIh'    pi.-iLiiii \    "f   intl'di. .11.   an, I   lii,  r,  r..iv  aiv   in..rc 
rii..jiiiiilK   alta.'U.'.l. 

i;r,...v.rv  t'r..i 11'   alla-'k  ..I'  ili.'   lii-ca-r  atV..r'l-   in  lln'    inai..iily  .,!' 

,a-.'-    pr..|,.,'ti,.n    I'n.rii    -iil.-,',|ii,'nl    altark-   llir,.iii:li..iit  lln'    ivinaimlfr  ,,l' 

11,;  .       A   nninl'ir  ,.1'  in<livi,liiai-  aiv  atla.'U,',!  a  ><■.■ 1  tiiiif.      'I'lic  ..cnr- 

,.,.,,,■,■,. I'  ilir, li.iir  atla-'lx-    in    lli''   -aiii,'   |.cr-,.n  i-  iii,.>t  ,'\,T|.li,.iKii. 

Aim. .-I    ,.\,'r\wh< '.'.    ,'-iM','ially    n| lli.'   c.nlin.'iit    >•*'  Kiir,.|..'  ami    in 

l-amlan,!,  llw    liiai..iil\    ,.!'  ,':i-<'-  n\    tv  i,li..i.l   tI'Vcr  .«','iir  in  tlir  latter  |iarl 

,,t'  ,|„.    \rar in    lli,'    lal,'    -nninnT.    lli,'   aiitnnin,    an,!    ill,'    I'arly    winl.r 

111..111I1-.       in   .■..nlia-l    wiili    lli''   ti'ii''     |"-lil<ii,'i-,    ty|.li,>iil   ll'Vcr    lia-    a 
t.n.l.n.'S'  t..  ....ntin.'  il-.-lf  l...'ally.  -,.  tlial  il  .•..inin..nly  .M-.-nr-  in  -|H.ra,li.' 

.a-.  -   ami   -roll]'-  "f  -n''li    ''i-' li,,ii-,'-<'i)i<l<'nii,'.-   an,l    -lr,','l-''|.i.l,'nii,'- 

— aii.l  iimliT  -[..'.ial    ,.,.n<lili.>n-  il  m  ly  Ix'  .li-triliiitcd  ,.v..r  an  cnlir,'  ,  ily 
,.i'  l...'alil\. 


m^;3m^^i^ 


:.:^M»^Amm^ 


/■I  I  ll'il.ni,  r. 


79 


II.    PArHOLOGY. 

GENERAL   SYMPTOMATOLOGY. 

V>  \\  .ii-iilc  iiiti-"iiMii-  ili-,:i-c~  (sliiliit  >ii(li  i;ri  It  \:iriatiMii.  ;i~  I\|p|iiiiil 
H\cr  ill  tlicir  iiianriir  <A  un-ci  ami  llirir  ((hii-c.  (  )iic  ma\  ,-(■<•  tlir  iiiiM- 
i-l  attack-,  la-till:.'-  mily  a  liw  ilav-,  -laiicK  cciiiiiKlliii'^  t!ic  patiiiit  to 
lakr  to  hi-  iiiil,  i\(ii  -rar.civ  allciidcd  w  iih  a|p|)i(<ial(lc  t(\  ii,  a-  well 
a-  -cN  tic  attack-,  la-tiiiir  many  week- nr  c\  cii  iiKnitli-,  with  liiLih  ti'ver, 
liiii-i  |iri>|iiiiii(|  ;^cin'i-al  aiicl  |im  al  iiiaiiite-latinii-,  ami  in  certain  ca-e-  Inii^ 
|(l'i)t.acl(K|  ecpiivale-ceiice  ;  ami  it',  tMoeilii.r  with  ihi-  jiidt  lacted  t\|>eut' 
<li-ea-e,  oilier   ca-c-   are  ol)-ci\ci|    in    which   liie  di-ea-c.  -ettiii;^    ill  with 

niiii-nally  -c\cfe  inaiiil'e-tation-  tfoin  tl t-et,  ra|iidly  attain-  an  alariii- 

iiiir  inten-ily  and  |iro:;i-e--e-  Miiiiitifrii|itiili\-  to  death,  the  (|iie-iioii  will 
rc|)i  atetjjy  afi-e  ill  the  face  of  -n<-h  di\er-ity  of  inanil'e-tation- :  Are 
I  hey  to  he  ivferred  to  a  coiiinion  eaii-c','  it  cannot  excii  he  -aid  that 
:tL;e,  -e\,  or  the  ccmial  condition  ot"  the  li.Kly  exerts  a  detinile  inlhielice 
llpoii  the  ;-oiif.-e  of  the  di-ei-e.  i'.oth  in  ;:-cneral  aii'l  in  detail,  faetol>  of 
an  iincertain  charai'ter  are  hi'ie  to  he  dealt  with,  aiiioiii:  which  |Hi--ihi\ 
the  inten-ity  of  the  infection,  certain  |ieiiiliaritie-  ot'  the  \  irii-,  and  the 
])fe<li-|>o-itioii  of  the  inlictcd  indiv  idiial  |>la\  an  ini|«irtant  jiait.  Aecord- 
iiiLdy  it  is  not  po— ihle  to  ^i\c  a  ^icneral  ile-cri|)iion  of  the  coiir-e  of 
typhoid  fe\-er.  It  will,  however,  he  ii-efiil,  in  conneciion  with  the 
tiirthcr   di-en--ioii  of  the   -nhject,  to  -ketch    in   outline  the   piclnii   of  a 

moderately -evere  or  sevei'e  ea>e  of  typhoid  fe\cr  teiniinatiiiir  in  u \«tv 

in  a  |H('\  ioii-ly  healthy  adult.  In  I'oiinectioii  with  this  description  the 
pathokiijfie  anatomy  aii<l  symptoiiiato|otr\  ,,f  tvphoid  te\cr  will  he 
deseriheij,  and  then  an  attempt  will  he  made  to  idii-idcr  the  various 
lorms  of /'oiirst.  in  so  t'ar  as  they  lia\-e  theoretic  and  jn-actical  si<rnitieance. 

Period   of  Incubation {•"rom   the   niument  of  entrance  of  the 

pfiii  into  the  hiHJy  to  the  heirinninu'  o|'  the  inori>id  m.-mili-tatioii  to 
which  it  i^ives  ri-c,  a  iiio-t  varialile  piriixl  ot'tiine  appears  to  elapse  in  u 
ea-e  of  typhoid  fiver.  It  is,  thcrcl'ore,  tiir  mure  ditUcnlt  to  deterinine 
the  periiMl  of  incnhation  than  in  the  ease  ot'  soini' other  a<'iite  infections 
disease^,  ;is,  for  instance,  the  acute  exanthemata.  Kveii  tiic  time  w  hen 
the  eonia;:iuni  is  received  can  hut  nirely  he  estahlislied.  as  this  is  not 
eticcted  hy  mere  presence  in  the  neiirhhurli(HHl  ot'  the  ])atieiit  or  simple 
contact  with  him,  hut  hy  pr<H'es-es  that  are  not  suscoptihle  ot'  direct 
ohservation.      Nor  are  the  conditions   more   tiivorahli'  with   rejrard  to  a 


W) 


/  1  iii'iil'  1 1  \  I  I: 


Hi' 


;?;■ 


|„v,i-,     (Irtri'iniiMli r   ill-    cii'l"!'   ill.     |Mri..,l    mI    niMilKill'.ii    :iu>\    iIm- 

iM-niiini-  ..t  iIm'  ;iiln:il  .li-..i-<'.  lli'  ili\  hIiiil;  lin.  I.,  lu.ni  ulii.  Ii  i- 
ii-ii,ill\  inili-liii.  I.  r.Mii  llir  iM-niiiiii-  •■!  iIk  U\iy.  ulmli  iii  Li'iiifiil 
j,  -iai,,l  |,  \,r  iIk  riiM-l  ivliiililc  -i-ii  .4  ill,-  Im -iniiiiiL:  •>llli'  ;i.  Iiuil 
(li-r.i-i  .  i-  -iil,|.  ili\(  1\  I'lliii  -II  linli  iiMik'ti  iIkiI  <\cn  illll  lll^tlll 
iLiliiiil-    iii;iKi     iiniirlaiii    -l;ilciiiiiil  -    in    i  •.iiiii  i  1  i.  m    1  Im  n  w  ii  li. 

T  lUiliLT    ;ill  "I'   llii-   inl'     I'll. -I'll  i:ili..n,   tin     dnfal  i..ii  i.l'   lli.     \><v\..,\  ..I' 

inriiliali'Hi  iMM    lir  -laii'l.  iiiiiiiilni'/  {•■  iii\    .  \i.ri'h mi  .  In  Im    trmi '  r 

luii  lit  iImv.nmiIv-.  I  111'  ia-«-  an  ui'il'iv  "t  lilll''  n  i  .liilil  \  ,  ami  in 
aiiv  iMiil  an  -ii-i  v|il  iMi'  "f  varviii'^  iiih  i|.ivlal  imi.  in  uliiili  milv  a  li  u 
li..iir-  <la|-r  liiluii  II    inliilinn    ami    l!ir    iM-lnniiii;  nf  I  li''  di-c-a-i-.      'I  lif 

,,l,-,.r\ail la  :;ivall\    |.r..|i  ni'^iil  |i<iiiiil  nl   imiilial  imi  a|i|.(ai-  In  inr  lu 

Im'    IT    |ir..lialili'.       |-'.\r|-\     ,A|ii  lirm.il     |ili\ -iiian    lia-    ..l.-rrvnl    ra-r- 

ili   whirh,    niaiiv    \Mcls-    lirlnn'    tin llnvaU    ..f   Ivplii'iil    (l\rr.    -.  iirral 

Mialai-r    .Ai-lcil     tlial     ii|"'n     )ni.-l     raivlnl     (Aaminalinn     i I'l     iml     I"' 

idrirKl    III    liiial    ili-ia-i.  ami    in   u  liiili  I  In-  |ial  i'lil-  (IraLliliil  I  liiln-<  K  i- 

:il I    :inii    lill    a-   il'  -i  mii  lliinL;  \miv    unm-.      ^mli  ili-<iilim'<l    laiijrmir 

ami  imli-iii.-ilii.n  in  lln  pn -iikt  nl'  liniinal  IhhIIIn  h  in|irralill-c  ;lliil 
al.-.iiir    iif   liK-al    inaniti  -lilii'ii-    :'r''    n-'i'il    in     ll"'    |"ii"'l    "I'   im-nl'al  mn 

(il    I\|ili..iil    f.Ai'i-,    in    ci.iilra-I    uilli    -iinilar    jiiii'il-    in    nllnr    infrrt - 

(ii-i-a-r-.    a-,     lin'    in-lame,    llii-    aiil'r    .Aaiillu mala     ahvailx     niillli li. 

wliii'li    iivmralK    'j:\m-    ri-i'    t inanili-laliMii-    ilnrin-    llii-   -Iai;v. 

An    atliinpl    lia-    Ih-.ii    nr    Ir    In   ili\  idc    llic  |ii  riml   uf  imailialinii  nf 
ty|ili.ii<l  frvi  r  iiitii  il  -li'.iii'  "•'  '■i'ini>lilr  laliiicv  ami  a  inii-  [.riMliniiial  -laiic 

,|i;il  j,.  tlir  |Mri.«l  <.r  inililinilr  \«M\   (li-niil.ami-.      'I'lii-  i-  |Hilaiilir 

ami  n-ili— .       ll  i-  l"-t  in  -av  tlial  lln    p.  rinil  >,\'  iiinilialinn  i-.  a-  a  rule, 

(MviipiMJ    wlinllx   ..!■    in    i>ail    l>\    imirliiil    il'c-lal imi-,  u  liil<'  a    -mailer 

llilinlHTnl'  imlixiiliiaU  iiif.vlnl  willi  lv|.lini.|  i:cnn-  iiia\  nniaiii  cnlinly 
fnv  fniiii  -\ni|)lniii-  linrim/  llii-  iMimd.  An  .-liinatr  nl'  IVnin  't  tn  lO 
IMP  (•.■Ml.  I'm-  iIk'  lallir  ,-niu|>  will  pinKaMy  mil  Im'  Inn  lii-li. 

Ai.iniiir  llii'  piim-ipal  inanirr-ialinii-  nl'  llir  p.rinil  of  iiii'iilpatinii, 
lanirimr.  a  -.ii-e  nf  <lra\\  iiiir  in  tlir  i  Alninilir-.  Iiradailir.  sicial  pain, 
di-liiilM-d  -liTi.,  at  liim-  Willi  ni-lit-wi'at-.  tna\  !"■  in.nt  iniiMl.  'I'li<> 
appiiiK'  i-  ir.mnills  iiiipaiiiHJ.  iian-.a  i-  pn-ciit.  tlic  patinit- .•ninplaiii 
(.1'  a  -CUM'  <>i  prcssmv  in   llir  rpiira-triuin.  and  nt'ltii  tlir  iiowcl-  an-  loii- 

-tipatfd,  altli..ii._r|i  diarrliia    al- ay  lir   nl.-.  r\i-<l    al    tlii-    ^tairc       I'lv- 

vinii-ly  li.althy.  -Inm-.  aii.l  .iinu.li.'  p-r-m-  nintinn.'  wlmllv  ..r  in 
pai-t  in  ilw  piir-nit  ..I'  tli.iv  wi.rU.  and  cv.ii  \\niniii  may  .■..iliniic  in 
tli.ir  ai'li\il\.  Oli-crvatinii-  ,it'  llic  Imdily  t.iiipciainiv  al  llii>  Imi.^ 
di-,l,i-c  nn  i.r  liiit  -liL^lit  .Irviatinii-  In. Ill  lli.'  iKiiinal.  .v.n  in  -ikIi 
lialicnts    a^    ahva.lv    .xhiliit     iii.Tca-cd    >iim.  pliliility    to    l.rni>.iatniT- 


t 


>i^^^-.  ^^xii'^?r^^'''Tmj^JW^ 


•If  J 


/■  I  lllnl  III,  1  , 


81 


v.-irj.itiMii-    ;iii>l    .iiv    i(:i.lil\   c'liill<'<l 


•  II  iT'iiiiir    iiilii  I  III 


liiti> 


.li 


'|i<  II  :iir  or  >J^v\\\\\^r 


I  III'    :ii  I1..1I    I'olMliii'lK'i'iiii  lit    III'   ill,.    ,|| 
ill.     |i.iliiiil-  lAliil.ll    ill.'   lir-l    iii:iik,,|    |,.|,|i| 


•a-c  ilair-  iViiiii   1 


ii'  liiiii    w  hill 


"■  -\  iiiiiliiin- 


iiii'iii''  :ill  .if 


III.'  -i;.^-  Ill'  ill. 


1:111111111:  ..r  ill.-  'li-i-a-i  |l|.-. 


.all  III'  lic-i  iji'lrrninii') 


till 


■liN.'lv.        Mlli.iiiirli '    .'lini,.i.i,i-    .lal.'    ill.     lH'Mitiiiiiii.r    ri'iiii,     tlic 

"'-•""-  '"  '"■''  '"•  '!"■  :i|'l"'"'' -f'liMrili.a,  tlii-  i-  JM.I.'liiMi,'  aii.l 


I'lii'  .liirati r  ill.    Ml.'        I  iiiaiiil'.'-lali 


."II-    III   U.  Il-<l.'\  ( 


■a-.'-  I-  1;.  II.  i:ill\    Ir.iiii   I  III-,,.  I 


I".  .1    .ji 


'I'lii-    |i.  ri..,i   .,r  ill,'   ,|j.,, 


i|i.'<i 


mill    \aii.iii-    -1: 


:i'l\-iii.-i-,  llial  ..r  a. -III.-,  an. I  that  .if  mi! 


iiai.i.-l\,    tjial    .if    ji 


aa-i.iii    ami 


ili-i.|.-ii,-.'   .i|    ill.'  ^\  iiipt 


Of, 'II  a  .'la--il 


|>l.iMI-    lit     III. 


III.'  .'Inn. 


ii-at I-    ina.j.-    ..-.•m'. 

il  an  i  ill.'  a—.i.'iali'.l  anal i.-  inanif. 


Ill-    .-an     II.-    IIIlK      ;r|-. 


t  iiii,'-. 
llii'ir    ~\ni|it 


nii:  III  VM'i'k-,  lia-cl    ii|iiiii 

-tali. Ill-,  lull   wlii.'li    tlu'i','. 

ail  iiiatr   l..'.'aii-.'    th.'  latl.r  a|.|i.ar  al    .iilllrciit 

ll-i'    |il.l.-.'.i     th.     .|.'\.'l.,|,|||.'nt     .if    th,'    |y|.h.ii.|     |,'-i,i||,,    xvith 


|i'||in-.   Ill    th.'    tir-t   u.'.'h  ;    tlh 


if  th.'  .li 


inpl.tiiiii    iif   iiii,'-i 


■<a-i',  \Mtli    llic 
''I'll    Hl.'.l-ali.m  aii.l  .'xfiliati.ui,   i-   a-iiin,'.!   t -.•iir 


II  llii'  -.-.-.III.!  an. I  thii.j  u.'i'k,  ;  vvhll,'  th,'  f. 


if  ihi'    li.'aliiii;-  .if  t 


nrtli  w.ck  i-  .'.iii-i.l.rcl  that 


II-  aiiat.iini.-    l.'-i',n-  an. I  .if  I 


II    i-iiiitni.li-ini.'ii.iii 


H'lrlimillir    (•.IllValocCIICf. 


ill.'    f.'hl-il.i    -t; 


II:.'   .if  t\  jih.ii.l    t 


l>     ••Ihcr     lllf.-ti.ill-     .liva-,-.      th.'     l.,'j,ri||||i||.r     of 


II  |i.-al.'.l  .'hillii 


I'Vci    I-   iri-iiirally  markcl    In   ^jitrht,  oftc 


III—.       I  hi-  1-  ...  iiiii,-h  th.'  III!,-  tj 


1111:111-  v^itli  a  -nil 


.-Ti 


lal  «  li.-ii  .1  f.'linl,.  (Iiscjisfi 


li 


V.T     I-     tll.illMht     ,if.         It      i,     k 


-v.T,.  .'Inl!   ^iJni.iM    Miiy  .itli.r  .ii-.-a-,'    than    tvph,,i.| 


iiiiuii    that    tl 


r.'li'i'r, 
Ah! 


III.'  i:i-M 


Inal   I 


11-   ali-.ni'.'   iif  I'j 


l.'liillllillir     ;|||,|     ill, 


lil!    i-    t< 


-' '  :"  •■<•"    |i:i;i.-nt-  -till   h.il.j    .Hit    I 

iill.v  I  ik.'  1,1  ih.-ir  1,.-,|  Mft.'i-  th,.  lii'M  .•liiliii„.>< 


-l.iw    a-.',. Ill    ,it'  tjic    (;.v(T. 
i-ivt'lv.  the    iiiajitfitv  jrciicr- 


'riic    i:('ii,'i':il    -,'11-,.    Ill' 


til, 


>|.-.-li\.-ly    .l.-iniin-ti-ihl,.    w 


'lliK-s  n.iw  iii.TciiN-  [.ivity  f:i|,i,lly,  and   also 


iir.'-|).ini|-  with  tl 


if    tl 


K-    patiint.      T 


II-    iisiia 


lly 


wifk  may  i;i\..    ri,,-  |.)  ,1 

iiM-r  .Inriiii:  th,.  ,.v..|i 

•'iiiil    n-irnlai-.  I.iit   a.v<'l,'i-it,.,|.       | 


11'  m<T(..-,.  m  th..  f.'v.T,  nhi.'h  at   tlu- ,.|„|   .,f  tl...  tirst 


•  ■vati.iii  ..f  ih,.  l).Mii|y  t('in|M.nitiiri'  to  4((=  C 


Th: 


II  III  'iiii-i-  in   mi.l.li,.  Iif,..  tl 


|.iiN(.  I-  j:,.|i,.|,i||y  I'lili.  .,f  j,,„„|  ,,,„,[,,„_ 
11    v.iimi:.   iMvvi..ii-ly  Ii,.alihv  hkh,  an.l 


I'l-laiiv.-ly  nut  -,,  j_rr('at  a-  tl 


"■    m.T«-a-<'    III     |.lll-.-f|-,.,|||,.,„.y    i,    ^r,.|,, 


iihI  ,'hil.|i 


t.i  tl 


I'll   the   |i|||' 


II'  i-ii-\ati<)ii  (if  tc 


l"il-i'  1-  iifl.n  ali-..a.ly  .licmtj,..       With  tl 


!<■  ••I»'vati..n  .if  K'niiKi-atiin.,  whil,.   in  «,,„|,.„ 
<-n,t..  i-  jrtvatly  iiKiva-.i  an.j  a|i|...ars  i.n.|„.fti,,„al 
I-'nitntv.      T..war.ltli,.  ,....!, if  th,.   (it-st  u.vk  tl... 


|)li't<.|\ 


|M'<-M..ii-ly   .h'l.ilitato<l    in.livi.liial 


<•  cxccittioii  .if  .hiLlrci!  and  tin 


the   |):iti('iits   apiicar  cd 


.V   s..n>il,|,.   .Ii.n,,^,  ,i,i,   ,„.,' „|       .,-,,^,^.  ,,„„,.,,., ^  ,_,.  , 


ti^rn,  riiafiii.r   in    t 


'A   m    tin.  car-,  with  a  -en-,,  .if  iiit,.|i>o   |; 


i(.a(iai'h(.,  V(.r- 


iiiiriiDf.  and  tl 


M' 


g2  rvriinrii  i i:vi:n. 

.,,•„,.  ym-Mv  I  >  -<vmv  M  .•ninrortalilr  |H.-iti..n  in  c.nM.iii.'n.r  nf  i.ain  in 
,1...  sui-;.!  n-i,M,  Mn.l  iIm'  .Mninili.-.  I'."-!  i~  "t'-»  <l.Hinr,l.  w.ul.. 
i„„,,-..  thir-t  i>  -.ncrallv  |,.VM.nl.  Tl.-'  l-n-ur.  at  ti.-l  -1,11  .nmM. 
l,.,,vilv  .•oal.Hl.  x,.ll..«i-l,  uliitr  M,-  l,rnuM.  an.!  aU,  !!,.■  in,l.o„.  ,n.in- 
l.ra.i.'-f  ll,r  liii-  aiMl  tli-'  nnntli.  .-xliiLit  a  l.nclmc.v  I-  .Inn'"  l;'^^-"'' 
,1,..  ,.n.l  of  III.'  tif>t  w.rk.  ■I'll.'  n..I  inMv.|n.nt  ...■.•nmn.r  ..I'  .■piMaxi> 
at  Iln<  tini..  i-  ..nilr  .l'-tin.-,u .-.  an.l  in  -..n.r  lutim,-  thi-  nia.v  .,.-., n' 
.l„,i„^tlu    p.n.Hl   ..f  i„..Ml,ati....      -n.'    ta.ial  .■x,,n-M..n  ..f  tl,..    ,.at,.-..t 

i,   tV,.m    tli. l-.t   a,.atl,..ti.-.  ll,.'    f.aKMv-  nlaM.l,  tl».  .iM-k-  ivM,  >...!, 

;,„.!    Ilw   -Uin  H'.l-    In.t  an.l  .In.      Only  -Inrin-   tli.'  tiiM  Hvn  .lay-  ..1  iIm' 
t;.v..|'.l...-  -lijrlit  -u.'alin-  -till  .■N.-..i,ti..nalK   laU.'  |.la.'.'.  .-1»'.'   lly  .liinn- 

"  l'.' M-i'n,'.  tl...  tir-I  vv.-'k  th.iv  an.  -..M.rally  -li-lil  n.anif. -ta.i.m-  .m  tl,.. 
„,,  ,.r  ,i„.  ,v-,.irat..ry  .M-an-.       A  .nnnl..r  ..f  l^ati-nl-  will  at  tln>    inn.. 


,. xliil.il    a    .iry.  >li..i-t    .•on-h.    wliil-      tlii-     i-    ^K-.  nt    in 
Su>ci'|)tilil.'    |>ati.iit>.  it    i-   irn 


.ithff-    at    tii-l. 
...  .-..iM-.lain    ii..\\    an.l    a^^ain    ..f  incrca-.'.! 


.lilH.Miltv  in  l..vall,in;r.  <  )l.i.•.■ti^  .■  .Aannnali.n.  ..f  ill-'  Itm^-  ,^v  i.Taly 
.r,-,.|.,-..-  n.,thit..r  t..  a.v.mnt  lor  tl,i-.  alllionpl,    luT.    an.l    tln.>v  .l,y  ral.- 

nia\   III'  an.lilil"'.  , 

'lntl.oniai...-itv„r.-a-,-tl,..  ali.l.un.ni-at  tir-t  ..f  n.mnal  lonn    an.l 

„„t  .ii-t.'...l.-l.     Kx.'.rti.'i.ally.  - <•  nuf..ri-.i.  In-'n,.-  a,.,ia,vnt  t.^wanl 

,,„,  „„,1  ,;•,!,,  tii-t  ssrvV.  Tlu'  .riua-triinn  i-  n..l  .-anly  t.  .hI.t  ..n 
,,,,.-nr...  uliil.'  l.al|iali.m  in  tlu'  fi.lit  ilia.-  C-a  .l.n-  tmt  .  l.-t.  any 
,„,.,v-i.>n  .!.■  ,.ain.       In  tl,..  marnty  ..f  ...-.-    ,!,.■  l,.,u.l-  a.v  n,.nnal    ..,■ 

,.„Miua...l.       I n,n..inly.liin.  has.,    li-.n    a  t.-u    1 -t...,l-    ^^1,.V 

.lia,-,.|,..a    al.in..    in    H-  tlr-t    ,i.ri...l    a,.,.,a,-  n.  1,..  1.-  t,v.,n..nt.       Dnnn, 
,1„.  la-t  .lav-  of  tl,..  fn-t  u...U  -..„„■  ,.a,i.nl-  .-oniplain    -,,...,lat,...in.ly  .., 
,i„an.l    h..avin.-  i.i  -l,.'   l-ft    -i-L  .      In    "'l-'-    i"-''"^'-''    — ^''"''•y  '" 
,li,,.,.v..rn!  ..nly  on  ,.al,.ati.,n.  an.l  ,-  .l..|i..n.l.„t  „,....  h-.-ininnj:  .nla,-.- 
nicnt  lit"  tlic  -|)l<...n. 

•r„w.,nl  til..  ..lo-'  "I'  '1"'  fi'-'  "'''^  "'"•  1'^"'""  '"-""  '"  ='!'!"■"•■"•'' 
,,„.  „,„..  „,  i;,-,i^rinni  of  tl...  .li-a-...  l»n,in^  llw  f.llouin^'  vv-.k  an.l 
,„,,„„,.  „,,  ,.„„li,ion  i-  .•onM.an..iv..ly  -.,•.■.  K.o,n  ,1,..  anat.i.n,.-  -tan-l- 
,„:i„t  ti„.  statr-  i-  that  of  .-on.^l.t.-l  n,...l„llan  -u.llin^  of  ['..y.-,-  -  ,.a...|,..- 
,„,1  tl,..  -.ililaiv  f.,lli.-i<-  an.l  tl,.'  a-.i..iat..l  an.l  |.,-.i-.v-,v,.  .,...to-,-. 
■n,o  fVv.f.  att.'v  a  -t..,.-lik..  a-.-.,it  .In-i-,^  -I.  ti,-t  u....k.  ,va..l,..-  M- 
l,i,.|,...t  iMiint  at  tl,..  l,..^innin-of  tl,.  -.■.-on.l  xv...k.  ..r  ,t  n-.-  to.  -.:-1,-,n 
l.Cri,..,.  1..V..1  n,.  to  .1,..  mi.1.11-  of  ,l,i-  u..,.k.      Tl,....n,iM-,-a.nn-.„i-v.f.r 

,  ■  „,i„.i  „,■  ,  sv....k  .If  a  «...k  ami  a  half  im.-.i.-  «li.^  - '-■  "'   ^'  '"""- 

t,.nt  ..onlinn...!  fivr,-.  tl,..  va,-ia,i..n-  li..;vv....n  morniiiL'  a.i.l    ..v.,,,,,^    l.-.,i- 
,K.,.m.n.  ^.•an..lv    ..x.-.....li.,^   tli.    no.„,al.      It.    tnikkr  -a-.-,    u    i-    "".•. 


I'MllDUxiY. 


83 


il."  'ImiI.v  variMti.,,,  in.-.y  n.-w  l„.  nw-iv  .■.m-i.l.niM,,  mul  triv  ri^..  tu  mi, 
""•■nn,tt..Mi  ..v,,,.  ,„•  (;.v,.r:  ul.il.,  „„  ,1,..  „tl,..r  lu.n.l,  i„  ,,,>,..  ..r..,, „..,■,! 
-vcrii.v.  ;,l.,„,nnallv  -li^it  v.riati.ms   ,„.v  n-ult    fl.r  ,|mv<  in  ;.i,  ;,l,M„.t 

';'"' """"•■*'   '•■^'■'■-      ^\'i"'  '■'-^"■'1  <"  th..  ,l..,r,...  of  ...,;,|,..n,M,v  i.M.lf 

iIm~  in  rn-,-  ,,l  MHKi..,-,-,,..  M.v.ritv  will  nuvjv  l„.  |,..s  liui,  ::i.  C  i„  ,|„! 
tM'.^HM.^  I,  Muv  n...-l,  ((...VM'.at  nud-.l.v.  mm.I  in  ,|„.  ..v.nin.r  it 
iM.-,x   ulrrn  n-..  -till  i,i.j„.r,  ii,>  t..   11-   ( '.  :m.|  cv.n  ;,l.uv... 

Wi.l.   inriv.:-,.  „r  tl,..  l.v.r  il niplMinl- of  tlw   j.Mti.nt   -n.limlly 

'.'■■""'•  ."■■  '""  '"  ■'"  ='!••"'""■'■.  -tM|«.nMi>  -tat,.,  a.xl,  altlM.u^rj,  .„  ,i,.^;^ 
n.   -o   far  a>   lM.oi„niM-   iiM|,airni,.Mt   of   |u,,ri.io    ,„.,.niii>,    l,.."-|,„r,.i.j,lv 

.v>|.un.l-   t„  ,iu,-;i„„-.  it    Im,- ..>    iiinva-inulv  ,litli,.ilt    n.   .naim-.'in  l,i. 

Mlt-Mt.oM.  |.,,rti,Mat,.|.v,  !„.  MOW  ,„t,.rs  a  .taf  of  „aivo>i..  S|,oul.l  n..vv 
;'""H;">i.~  afiM.  at  llii.  tin,..,  or  -houl,l  ,.,-..vio„,  ,,ain<  iiM-.va^o  i» 
iiilcii-ity.  roiri|,|i,:,lioiis    >lioiil(|    I,,.    |,K,k,,i    (l.r. 

DMfi.,,^   ,1,..  ,|.y  tl,..   |K„i,.,„s  >..l,|o,M   .1..,.,,  ,i,,.,,lv.      (;..n,.,allv    tlu-v 
H'   with  .,|M.„  or   l,alf-.los,..i   ..V,.-,   in   a   lla.vi.l  ,|o,>al   .|....,.l,it„:      Tin. 

!;::"''~:''.-;'"^'"-"'"^-^"i '•"•'■'i">-^"Mn.a,von..,.  K...„,,i,..ii,v,i.,ii,i„„, 

""•    ''"■'^''  <M"-'"i-"    ,irra,l„ally  I o,„,..  ,|raw„.  .,,,.1  tl„.   jm'v  io„s  n-l- 

n."  1-  n.,.la.-,|  l.y  pallor  wi:l.  -li.l„  ..v:,,,,,,;..      tIh.  , tl,  i-  l.alt-op.M  • 

""•   "i'l--  lip  .vtra.„..l.  .,  ,|,„    til-  Mpp,.r  „.,.tl,,  ..ov,.,v,i  with  a  fnli.i- 
.-u~,l,.p,M,,.,v..xp„..,|.      Th,.lip..n.,lr>...„v,.rnl  with  .lark™, 

^'";'     ''-I'lr    l'l<-<liMj.    tron,   -li.|„     ,i~,„r...       T!,..    ,r.., .„,,    , „„ 

:,''"'"    ''"•   -"•"■  ^'I'l'-Mraii,-.  an,l    towar.l  th.  ..„.!  of  th..  -....o„.|  ,u.-k 
"    l™— mall    an.|   thin    ,n„n   ..xloll.tioi.    of  ,.,•,.,-  an.l   ,.pith..|i„ni 

"""^;-'; "'•'■'■•'   -'"•'-•"-"!    p.TM.t,n;,  ,lnn..~>.       Vi.  i,|,  hrowni-h 

sin,n,i„ol..,„.  „,„,,   .,..-i,.,.„.„|    „,„,„.  ,,„|,„,,,„   „.   „,,.  ,.,,^,^,^  ^^^^,      ,^^^^^^^; 

',    ,  '" ,""    ""■■"'"•^""•-    'I <t    ■■uu\    ,|„.    hanl    p.h„.,      Th..  vo,.;   i. 

:■■'•    'i'    '■'■"';''-  "'"'•I'"-  -"'   ="    <im.^    po>Ml,ly  hoar.,      | „„„.. 

I'l'-'-l—s  tlupul.    w.till.ulla v^nlar.  though  a......|..r.t...|.  .n.l 

-"    <'-   "'=lhrity   of......   i„ark,.,lly   .li..roti,..      Th..   l.r..n,.hi,i..   niani.;.,- 

•ano...  wln,.h   w,.r,.   hut    -li.ht    .hirin.   ,1,..  ,ir„  w....k w  alino-t   ,- 

Mantly  u„.|.,.„  ,.xa,...rl.atio„.      Th..   ,lry  .-oi^:! t    nnvlv    „■ v.   .„.l 

-  Murh-   ,l„.   ,.at,..,.t.      Kxaniitiatioi,  of  th,.   1,,,,^.  ,li...|o>,:>  th..  m,.„  „f 

''"":".'"■"""•'""'•'-' -I'v  -'--k...!    in    .h..   ,H,M..rior   interior  portio,,, 

wh,..     „... v..,.,.  ,..,..,„..   1.. ,„,.tl a.ofhvp..ta,i..oroth:.r,or,.,: 

"I    Mitlaiiiniat.irv   ..oii,o|i,|;|,i,,„_ 

r,.„.   th..  hot.  .Iry  skill   th..  w..!l-knowM   ro...ok.-  .pp.,,.  .iurin.  tiio 

'V''-~  ;'"'"■   ""'"•■'■'^ -    rar,.|y  ,.v..n    a,    t .| f  ,h..  ,;,., 

;•••'<-  ;'"l';;   '■■nil   of  ,li,htlv    rai...l|ivp..r..,ni...po„   var^in,    i„    .i... 

""^''"'"' '•""•'-•'^- •"'-'"■"  '"-null' of  tlK...|,...t...xt..,i.k  if  pr,.'..„t 


ip..' 


84 


rvriioiK  I  I'y'i^ 


lit-. 
II 


V- 


R:i' 


I  il,..  tl.i.rl,,    wliilc  tlic  forearms 
,  ,,,     , ,  ,,,  ,,,rlv  an.l   :1.-  far.  i-  n.v.r  ,ktuiu..1   1.>   th.  .n.         l- 

:':::!:;:;:::,::;:,r.l:^::.^"- ■ -■■' • 


tra<ir.l  <a-..-  -till  lanr. 


trarici  «.!-<  -    ",.  (■  .1,..  iliM'i-f   i-  ni>riiial  I'P 

,..,,,„..       I'--'  ='•'-     ;^"       '",,,,,,,,,,,,,,,,,,,,.,,  .,..rrlK.a ur. 

«-- :- :"'"'i™i  :::;;■'''':;,■:!::::-,.' o.  ,.'.«■ 


,.va..uation<  in   tl.c  twrnty-foi.r  h-ur-      1 


r'"'''rn       ;  .-,    an,liuanun,..r>l.-^^^ 

;^;r  •;;':::;:::::.' ■:;... ■' ^ ■ ■:•■',;"■;;■:;""::: 

.•'-'-'' rr  :":';";::::'■;' 'i".i. -■>•;- ■ 

,i,i,„.   ,„v.,li.i.nmK.    1M..I    I'"   ""  i.„..r..-iv.-  .ni-.lia.- 

" ;- ' '^';'"';-:':;i.':;:;::.:::;™":^^'-"" 


turv  aif.M'linn  i.f  tlu'   lunt:-.  ">"■ 


""•>  ^""""" "      ,.  ,,,  ,„,,„;,,„i„„    l.ut  furtunat.lv  not  >■•  tn- 

;;::r:;;:::^::;'::-:i:- -■"^.rr::"::::::::;^ 

■»'•- ;■"-"  •"; "■■  ;„:,;:,;.  ..;  .1.  ■< ■.-■ 

tlu'  iiaticnt   inav  l.f  .'nilan>r<  n<i   "_\  |  c  .1,,.  .l.-.-i-c 

tl    ii.i..n:a.  n.,v  l.v. -leveloH   -1'-'..   ''-;--•  •;''^^'^^^^^^^^^ 

-,,„,  ,,,,v..,  att.T  at    tM.t.  ,.,..U...llv   an.l   .'ft.^n   .•xtr.Mn.ly 

1k,v..   ,,r...r.l..l,   Ik .no>  .lu.rc  -r   U'->  nia.k..llN 


l'.lTllnlji(;y. 


X." 


iiii.TMiillfiil.  Willi  a  .Ir.liiiiiii:  l.'iul.n,  V.  Tlii-  i-  .l.-i-MMl..!  tli<.  ^tajre 
-r  -I.,.,,  ,.,ii-v,.-  •I'hr  piiUr  i-  ,i,,w  Hnall.r,  tli..  Imii.^i.  of  t\w  art.ry 
iiiun.u,,-,  ,|„.  .li.roiiMM  l,a^  -li-appraiv,!,  and  tl.r  irimv  ncarlv  tl>,.  fin"- 
I-I-.IIM1V  a|,pn,Ni,naf^  thr  i„,n,ial.  ll...  l,.>s  l,,.,,,„.,>  the  rn",|,i,,i,v  .,f 
ill"    |.iil-c.    iini    rarely   ;:i\  iiit:   way    to   l.raiK .  anlia. 

Kv.n  .liiri.iir  the  -ta-e  of  m.m|.  .-Mrvs  the  ~i<i„  is  likclv  u>  1...  incist 
at  linu-.  Til,.  r.>-<ola.  irni.iiially  fad.',  and  tlu  y  arc  ..rtcn"  r(|,la.v.i  l.y 
an..llirr  -trikiiiir  .-..ndilinn,  riani.ly,   ndliaria  (•ry>ia'liMa.      Tlir   li|,..  and 

''"'    """•""'    nMM,l,-an..  uf  th,.    i th   al>n   l„.,',,n,c  elcan   an.l,  t.-jrctluT 

vvitl,  the  t,m-Me.  In.,.  ili,.ir  dryn,--.  Tl...  a|.|Ktif  and  ili,.  M,rs,.  .,f 
tlnr^l  r...nr,K  and  ili,.  patirnt-  now  JM-ir.  t,.  a.k  tl.r  to,«l_a  ,k.,„ai,.l 
that  «o.,M  iMMnnic-  !■■  „;■  i.r-.nt  and  wliirl,  ,,(i,.„  ^W,..  H,.,.  t„  ann..v- 
ni-  ditr.ivncc-  \\--'  ;„.  ,,|,yH,.ia,i  and  tlic  altcndani..  Uitli  tlu' <l"(- 
'liii.-f  th,.  irnijxratnrr  the  palicnt-  \„-/u\   tn  niak..  .■..tnplaint-.      TImv 

'"■'■"""■  '^'•■'•''"" •  i'-fitahl,— all  nmnir.-tati„n-  ,,f  ntnrnin;r  c-mManus- 

n''>S  an.l  at  the  sinic  iirri<.  uf  an  appr.viation  uf  tluir  li.lpl,.v-n,..-.-  and 
waknr-.,  wl.i.l,  an.  -h„wn  aUu  ul,j....tiv,ly  in  ;rr,.at  ,.n.a..iatiun  and 
P^'l'"'--  l'-t-tMnai,.iy  f.r  ,1,..  paii..nt,  ^Ir.p  n  tnrn>,  and  uitl,  a  di-ap- 
I"'^"'""''  "•'  ii"<tnrnal  nMl,..>Mr-.  a.,d  dr.an,.  tl,..  u,|„.r  arniuvin- 
inaM,lr~iatiu„>    likewi-,.    Mi^.-id..   j^radnally.      Al.uv,.  all,   tl,..   l.r,.i,..i,itis 

''"•' ■"•--""1   ^'i'!'    |'>i.innuni.alt...~.ti,nsa>l,av..  .l..v..l,,p,.,I   <nlwi.U. 

II"'  .■tiiaru.ni.nt    u\-  .1,,.   -p|..,.„    .liM.ini>|„.s ;    ,1„.    ,„i,M.    I,......,,,...    ,n.,re 

:''"""'=""   ^""'    ''■-'""•   i' '">•.  ^'^-^'i"    I'v,.   fn.n.   all.nn.in.  a,.,l  at  tin,... 

!'  '''■'"  '■'" '    '"  """-iiall.N    lar-..  an,u,n,t.      Tl,,.  .lian-lna  uf,,  .,    p,,,..;.,, 

"itn    til.,   alilnil..    iMriud,    ih,.    ^u«,\-     l„,w..\..r     .rr„l,,.,llv     . 

•  '      '  •    iiuH,\,i,    jria,ii|;i||^    .K'fiuirin.r   a 

.lark.r  cul..,-.  "  '  • 

Jt.    tayu,.al,l,.    ,.a..,    ,1„,    ,,„i.„,    nuw   ^,-a.i,.allv    I,..,.,,,,...    fr,.,.   (r.,,,, 

^'?'"':  ,    '."^7'-*'  ' ••"'  "'■  "-  "-■<'  "'•  i"  tlu.  tunnl.  .v,...k  tl,..  pr..vi..ns 

l-iiyMu,,^,..    l,.Kly-,..M,p..,-a„.,V    i.    .,.„,.„d|y     ,.„„„„.,|,     „•„,    „„,    „,„.,^^^^, 

.  nyll,...„.atiun,an.l    in   all    >..v..,-,.  ,.a<..s  ,1„.  „.,„p,.,.atn,v   n>nallv  falls 

>-ill     n,-,l,..r  l...|uw  ,1,..  „ur,„al.  .„  ,l,ai  n.urnin,.  ,..,„p,,,.„„vs  „f  ;i,;=  (• 

•"      ,'■"'  ".'" "'"-   '«>M|KTat,„-,.  uf  n„.,,|v  n,„r,.  ,l,an   .•ill.V    ('..  ,nuv 


1>|.   til,. 


!■   nil.,    tu,-  .la.s  ur  ..\ 


'v.'n  w..,.k~.  Tl„.  pnls,.,  wlii,.l,  is  -  ,,,„.i;,li;- 
^.nall.  ,  !,.„  „,.r,.,,  ..„t  a,„l  -luw.  i-,  lik..  ,|.,.  l.,Hlv-„.,„p,.n.,n,-...  „ns,a;,k. 
n...l  .va.l,ly  va,-ial,i...  Sli.|„  ,„„„„,  „,  ,,,,,,,,,  .,i„„,,,,,„.„^  ^;^.^,  ,.^,, 
>"  -I.J.I  ..I..vat,un  uf  ,..n,p,.n„„,...  an.l  ..an-..  ..un>i,|,.„.M,.  „-a„si,u,-v 
;;;;■--'    '-■I'-n-.y   .,f  puV,..      .„    .tl„.r   n.-p....,s   al.,   tl...   ..xtr..n,..lv 

,:""■'  ■ ^^'l'—-'<^  ="•..  r..a.lilv  ..v..it..,|  wi,l,un,  f;...|i„.  .,sp,„.i,||,  Jij 

,      "'.'~   """••    1"'"^  "''■■'    '"•'■'■   I-    "..  .•..,npli,.a,iun    .„,    ,1„.   part   .,f  ,1,,'. 

.-M,v,.u,.,a„.,l,     .,.      „...l,il.i,.,r..a.l,..„„.,..      All  .,f  his  tl,.„.,l,ts 

■'■'-'  ""'"»on-  r,.v,.l...  a.,un,  ,1,..  i..^-,sti,.,.  ni'  f,..|,  an,l  ,1,,.  lar-as  ••uv.t.ms 


If' I- 


!l 


M) 


Tvi'imin  I  i:vi:n. 


CMS  wiili  wliicli  lie  t'l.llciws  cvirv  innvcini m  m|'  tlic  niirsc  or  llic  ])li\>i- 
ciaii,  I'l'cpin  ulidin  lie  li"iii  ~  t'nr  t'ulliliiii'iil  ol' lii-  dc-ii'i-,  :in-  ili:ir:ict<  ri-tii-. 
It  li:i-  :ili'(':i(lv  iiii  n  iiKiicatiil  tli:il  diiiini^  tiic  |i('i'ii>i|  iil'  iii\ diiitiiiii 
anil  that  nt'  ciiiivalc-i'ciirc-  llic  |iati(iil  i-  (xiiuMii  tn  the  daiipr  <ii  rctTii- 
(li-r(  lire-  aiiil  nla|i-i's,  anil  even  al  tlii-  time  lili'  nia_\  in  liinalincil  liy 
liiiniiirliaui'  anil  inti-lina!  |iiit'uraliiin.  Ainunj^  tlii'  nniainnii:  ilanL''!')'-, 
lHil--iitt-.  ri\-i|i<la-,  anil  al)-cr"i-,  the  Manila' i>t  ]iniiiiniiriia.  c^iicciallv 
]>lrnii-'.'  anil  cniiiMiiia,  a-  well  a-  i>aiiiiiti~,  lyjiliniil  iarynL'ili>  with 
iilct  nitiiin  ami  lurni-i-  of  rai'tilaj:;!-.  may  lie  iiiiiitinntil.  (  liaimi-  in 
till'  iii\  iicai'iiiiiiu  al-ii  may  at  tlii>  time  a.-siimo  an  alarminfr  /'■/'.  Miii- 
ini.'iti-  ami  ullicr  xMi'r  lii-lmiiaiii-rs  im  tiic  ])afl  of  tiir  I'ciilia!  nrrMiM~ 
system  arc  lintmiati  ly  Ic—  cummim.  All  of  tln-c  anil  -till  nihcr  <lis- 
inrhaiKs's  -iil)^ci|ni  nilv  in  lie  di-iiihcil  in  detail  mav  i|iiiikl\  cause  a 
fatal  issiip  ill  tlic  euiir-c  <it'  a  tea  lnniiv-  or  ilay-.  or  alter  liiiii:-cuiitiiiiie(l 
>ntl'eriiijj;  nay  terminate  citlicr  in  recuvcry  or  in  death.  Ilii\\  lVei|iient 
arc  \\(H-I<s  lit'  Impc  ami  tear,  and  tinally  everythiiiix  In  liave  heeii  in  \ain  I 
\\  hen  rciiiveiv  tinallv  takes  jilaci  after  c<im|ilicatcil,  li'ni:-|iiiiii"actc(l 
ciin\alc-cenee,  it  i-.  liiitiMiately.  iiinie  f'iei|Ucntly  eiim]ili  le  than  in  the 
ca-c  of  manv  elh.  r  int'ectiiiii<  di-ea-c^.  The  |iatients  ^^enerally  ri'<-ii\-er 
with  rcmarkalile  i-ipiditv  after  -nli:-iilciicc  of  the  local  iiianil'cstatii)n-, 
and  their  nntritiun  iiii|)ri)\cs,  mi  that  thiv  |>rcMnt  the  uell-knnwii 
j)ietiire   uf  the   cunlented,  fattened    typlmid    com  aic-ceiit. 


SUMMARY  OF  THE  POST-MORTEM  CONDITIONS. 

The  fiilliiw  iiiiT  sectiiiil  will  lie  ciinijiaralivcly  less  cDinprcheiisive  than 
SI  :ne  mhers  in  this  wmk,  as  a  ]iart  uf  the  fict-  that  miirlit  lie  eon>iilei'e<l 
here  will  lie  ticatnl  d'  in  iitlicr  sectiiin>.  'i'hii~,  fiir  ciinv  ciiicncc  in 
de.-cri])tiim-,  detailed  slateniciit-  as  t<i  the  niiir|ihiiliiL'y  and  the  liiulnjry 
\>(  llic  tv|)liiiid-liacillii»  lia\c  already  liecii  niadi'  in  the  sceii.ii  on 
K'iciloiTV  and  will  he  made  in  the  M'<'tiiin  mi  I  >iatrn<i>is,  while  in  the 
scclinn  dcviilnl  til  an  aiial\-i-  if  the  individual  sym|itiims  it  wa-  im]>ii— 
sililc  in  manv  ]piace>  to  avoid  a  full  doerijitiun  of  the  anatomic  altera- 
tions. I  lielicve  that  thi-^  a|i|iarent  irrci:iilarity  ha-  rather  cimti  ilmliil 
to  coni|«rchc!i-ivciie— .  and  that  it  is  the  licst  mean-  ol'  cliiiiiiiatiii^' 
otherwise    imavoidalile   rejietition. 

EXTERNAL  APPEARANCES. 

Arcnrdin^lv  as   ilcatli    has   taken    [ilacc  dnriiii^  the  lir-l    .-tajrc  ot   the 

(li-easc,  whether  as  a  result   of  the  -cvcrity  of  the  infection  or  of  inte.— 

tinal    hemorrhairc,  or   ol    otlie!-   -iiddcii    aeeidciit    or    in    the   -econd  staL''e 

alter  iirotractiil  -ntl'eriiij,^  or  in  ciiiise(|nencc  :if  xveic  com|)li(•atillll^.  the 


% '"'&:  •  -w%^i:.m^f^m  3 


l'.\TII(H.ni;y. 


87 


7"'''"'  • •"'•="" "''  ""■  '-'>  -"^'v  '■<•  .li=nM,.,nn.llv  „,,,HM„..      T„  ,lu. 

"'■■"■^'V        '^    '-   -n,.n,ll,    U..1 M,,,!.  ,l,i,   ,U„   „,   ^.„., 

"r-""'^'";;:"''^""""— 1|'''-|" '•  ■•'.v-in-mK  ,l„.,...„„i,..,f 
' -■':' ;;-^' ';--•'■  i—,.ui,ii,., -la. ,.,■„...... ,i,„,..„r a,., ,..,,, 

^'''!";:"'''":.  ."'•; -'—"•-''-.-M.i,.  .,„i.i.,i  n,i.  -ivM I 

rxlnU-:,,|nnH„-l„..lt..„l,,„v,„, ,„h„i„„    ,„.|    ,,   „,,„,|i„„,,.  ,|.„.^ 

I  1-  l->r-VM.  an.  ,vn..n,llMilNW  u  hi,  ,|.,.k  J,,...,  ,.,,,,,,,,,,,,;;;  ,i^,,,^ 
:»-.Mr..,„ralK   tl,,.  -ra,  nt    ,.,,„-i,l,.raM,.  i„,l,il,i,i.,„  „,■  |,|.„„, 

II-    l"..l..~..f,l,„..  ,|..,lalWa    ,.n„n...,.l   ana..k    of  ,|,.,  ,,i.,,,„ 

"'"■".'"'"'"'•'."•""""-"'"'"•■ "•'•"-.'-   'l'>.'nl...l,..xtn.or.li„arv 

;:'""■""■"•    "'"'    '■    I'^'l'-    'l'-M-.mti"K    >kin ,.a.i..nMllv    al.s,.....: 

""•'.,„■,..  a,Ml   ..,.,.,„lan   ul.-.r,  .,f  ...,„si.l,.n,|.N.   >i....      X.„"  n.n.Iv  l„.|- 

-...v,  al~u  an.  ,,n.~..Mt.      A,  ,i,n..,  .Iut..  is  „|,.,„a  .hout  tl,.  ankl,.<  "     Th,. 

."H-.. ..,,..  >n..|,  ..as,.,  an.  wast.l.  ,.al...  a,.,l  in.ihn.t.,1  ui,|,  sennn.'      Th,. 

\:''-V''''"7     '^''''•'•-'''''''''--'^-itl.a,..n.U..vt..  tlu..;.n„a- 

""""'  i'-'i"";;"';"ii.v-oio.i,.,,..i.,„.    i •„,.., ,;„.„.;  ,,,,,,1.. ,.  ....i. 

....,:..   ..n,.l,,.n.n    a,.,.  ,,.,...,.,  ,),,.  li.s  of  ,,,,.„,,„,,„,,  ,„'„,, 

''/'",""■.'' l.i...n,„.  ,„  .iy„  ,,.,.,„,      ,....,.„.„,„.„,  ^, 

''':""'V~"' "l-'-'i-'v  iit.l,.   n.arUI.      'IV  t..n.l..„,.v  t,>   p.rnv. 

'"■' '"-   ""•    "'■--■l>--"l--t.MnM,.UIasi„,;,|..„   ' 


,  ,,,,      ,i;  ,.  """  "^  "I  "III,. I     i;il(.(.- 

■    ''•'"-."■■   ",-    '■"■   "'■'"""■•    ',> <--■-'  a.i.l    -.„„ll-,.„.       |,i„„, 

;:;:;:  i;:;::: — "'-'^ '- -•'  ->-  -"■■  '•.".•.■  .i»..'i.; 

MUSCLES,  BONES,  AND  JOINTS. 

'';'"■  =;i'i:"=-M,v  of  ,1,..  muscles  In  ...,„.n.l  |,as'l „  ,,,,;,,„,,  ,.,  i„ 

;:;,.i: r\  :i.  '"•■  "•;-';•  "••  • ">-•  t,,.  .,.: ,,. ,,,:;: 

•      .  .-■-    .IM,^  sn,,,  ..1   „,.,,   a„.,    p.,.,,,,i,,.  ,   ,,,^ 

'  '"  ""  '"'"•"'  "-'^  "I  tl-  -li—.  or  ..v,.„  la,,....  Th,.s,. 
,'"":;:  "'-  "'••"^'"^;  -•■'-  =•"  -'•  <!'.•  v„lun.an.  „,ns,.,..s  .  '  ;,. 
!>•       Il-vn,...   n„.-t.n,,M..ntlv..vi.l,.n,    in  rl...  lap...  ,h.,n.,.i..  mws..|..s 

..,..':.:•;:•;':;,. ^•■' '•""■ ^ '"'•• "^'h-- 

Tl'-     'nn-.l,.,,    „|,,,     ,„„,j    ,.,„;^.,,^,     tr,.,,n..n,lv    ,.xhil,it     n.ptuns 


ss  lyi'iiniii  I  iM.i: 

(if    |Mi-t-Mln|tilll    oli^'ill,    lllll    ll.ISc  (lc\(  lii|(.<l   illllillir   lifi  Allll'PlljrIl    tllCSC 

iini-ciil:ii'  l.iciTiilii'M-.  I"  wliiili  l>'i'kilaii-kv  (ii--l  ami  N'in-lmu  -iil.-i- 
<|ll('lltl\  CM  I  111  I  Mllclllioii.  (ircuf  :iUii  ill  tile  .■oiir-c  (ifiillicr  :l"Mlc  illfcci  iull- 
ili~c:i>i-,   :i-.    liir   iii-lMMiT,    l\|iliii~    li\tr,    llii\    :i|i|Mai-    In    !»■    (>|Miiallv 

(Vr(|llcllt     anil    rMill-isc    ill    cl-r-    ><['    t\|ilHiiil     IcM'l', 

'riir   mil  n.-r,.]!!.-  a|iiKaraiii-i'  n\'  tlic  iiiii-rli-  atVrrtol  in   tlif   maimrr 
ilc-ciilMil  wa-   ^liidinl  with   .-.|Mcial    cnv   l>\    /.iikri-.  wIk.  ili-liiii:ui-lii d, 

in   aildilinii    to   -iiii|ili' n-ilr^mcralix  .•   ali-n|ili\ ,  luo  uili.i-  vari<lic>  "I' 

(liurii'iMti'iii,  llii'  i:raiiiilar  ami  t'atl\.an<l  llir  waxy,  wliidi  lie  lliuinl 
irciKTalU-  a^MM'ialol  c;-  ninilpiiic<l.  TIk'  ["irtinn-  nt'  nin-clf  iimlcrirniiiu 
waxv  iir).M'iicrati<in,  c-iMTially  iMtwrcii  tlir  >cc..ii(i  ami  llif  tmirtli  -Mik 
tt\'  till'  ilisca-r.  cxliiiiil  llic  tinn  nu'-i-lriicy  alrraily  iiiciiliiiiic<l.  ami 
an  apiHanimc  al  tiisl  >triatr  ami  |)iimtatf,  tlini  irniyi-li  nd,  ami  siil)- 
s(i|ii(iill\  waw  ;^rav  u,  ti-li-inc  il-likc  ;  uliilc  llic  trnnmlar  ami  tatty 
(ic^rcmTatiiin  iinonio  iiiaiiili-t  i)y  cliaiiirr  in  (•(p1ii|-.  iiiarkril  |(all(if  or 
vrlkiwi-li  ili~(ul(iiati(.ii.  only  alter  it  ha-  cxi-tfil  lin'  a  kmi:  ti'iic  ami 
lia>  a'taim-il  a  hi^rh  ^railc  <it'  intensity.  'I'hi'  a|)|Maraiici'  nt'  the  (Irircmr- 
atfil  iiiiiM'lc-  niav  t'lirthtr  lucnim'  c-iircially  run-|iicm>n-  tVoiii  tln'  fact 
that  till'  licMiiirrhairc-  jh-ia  inii-lv  iiicntiiiiic<l  may  lii'  a-->iciatc(l  with 
the  (Icircmnitiiiii.  Al  time-  the  c\trava-:itiuii-  of  lilnoil  a|i|Mar  a- 
striate  ami  iiiii-ciali'  tiiinrc-.  wiiilc  at  cither  time-.  a>  has  lii^cii  incntmned, 
thev  t'onil  e\teli-i\e  lieimirrhairi"'  cnlleclioll-  with  (leslriiction  (if  till    lllll>- 

(Milar    ti— lie.       The    ili-triliiilii'ii    of    these    1: raticin>    ami    lieimirrhaifcs 

tliiMiiL'hiMit  the  mii-ciilar  sy-teiii  i-;  <|iiite  irreirnlMr.  in  euntra^t  with  the 
<li-trilpiition  nl'  waxN  ileiremralion.  whieii  •.litn  i-  symniilri<-al.  Natii- 
rallv,  tiiev  will  lie  riHiml  imi-t  lrei|ii(ntly  >i  tlm-e  -itiiati(iii>  that  are 
illViilvnl  in  the  ilee-ellrrative  ])r(iee>s  ill  jxrealot  (lej^rec  ami  earlie>t. 
.Vceciriliiiirlv,  their  |)iinei|iai  >eat  i>  the  aliddininal  re<'tn>,  more  ot'teii  the 
lower  than  the  njiper  hall',  the  ^rivaler  and  le^^r  peetoral,  ami  the  ilio- 
psoas. I  have  ohserved  tluin  in  .1  niiiiilier  oi' ill^tam■  s  in  the  liiei  ps  and 
trieep-  ol'tlie  arm.  and  remarkalily  sekknn  in  the  adiliietoi>  of  the  tliii^h, 
(iiiisiderint:  theii  lrei|iieiit  in\i'l\('iaem  in  the  waw  form  of  deireiierati<iii. 
The  further  di-int.LM'ation  <if  -iK'h  foci,  with  tli;  peculiar  chanp-  in 
their  content^,  has  often  iriveii  ri-e  to  the  opinion  that  inu>clc-lieinato- 
niata  mav  imdci^ni  -iippnration.      Althoiijrli.  from  existinir  haetcrioloMie 

knowliKlire.  tin-  po— iliililv    cannot    he    wholly    e\elllde<l.  yet    it     inil-l     lie 

(■xcecdiiiiiiv  imeoiiimoii.  True  miiseli-ai)-ce--e>  ill  the  coiii-^cot  typhoid 
fever  ap]K>;ir  to  lie  rare.  I  have  oli-erved  them  in  a  nimilicr  of  in-tanec> 
a-  jiart  maiiifc-taiion  of -eeomlarv  -cptie  pro.     -e-       Itivcntly.  attc-  ion 

ha-  lieeli  re|>eatidlv  ealle<l  to  inil-<lc-al>s.'c<-e-  dl-  to  the  pyo^renic 
nctivitv   ot   the   typhoid-hacilhw. 


/'I  I llnl.iii.y 


H9 


I  I.M>    (  Ml,n.lM„kv     I,..  „l,.-,.rv..,l   .li.ri,,.^    lit;.   ..„,   nU-.ss  m.  la, .-  „„ 

1^^::    n,    .lu.   ^r.:u..r   ,K.,.,nn.l    n.u.l..   ^hi,!,    ,.„„>Mn„.,l    „„Iv   ivnhoi  N  ,a 'i 

ll-..v..,...r.,s,..,Mv,.t  ,1,..  I-;i...,.,l,    l,M,-ilIn,   ,„    ,1...    livin::  l,.„lv.      T   .      , 

M..\u,  «„s  sui,„...,..,i ,,.,r,, ,  ,,,.,,,„,„,,. ,,.,_,  I,,.,,'  :„" ; 

•'ii'"''^  "I  lyi'l I  f'v.T  ill  s.|,irii,i„.|-,  i.s'.i:;.  •'" 

Tlir  bones   ;i,mI    ih,.  joints   .n-    inv,,!,,,!   ,mu.I,   I,.,,  ,.„„„„„„|v 
tl.';M,,l,  in    a    Miun.  v:,ri,.,|  M.ann.r.      AltrMti,,,,  |,.,~  I,,.,,,  ,linvtn|  ,„  .|,...,! 
I.>...ii~    .-^IK-Mlly  ,l,roi,.|,    ,|„.  „,.,k    ui-   K,.,.,,.-'      I„    |,i,    |„„,    „,„.,^    ,„, 
'■"l'""'l    2:!.    .-a-,.-   „f,.-,i,i.   a,„l    |«.ri,.Mi,i-.  aiHl    m,„v  tl,..,,  ,iMn„.roi.« 

'""■'■  '■'-'■'  ''='^"  "  '•"I""-'-'-      ^'  l^"-  ='>  lM..t..ri,.|,..i,.  iMv,.Mi..,li,„„  at 

I'i''-r,  ..,,  no,  a  Hiiall  umnUrv  n\-  ,.,..,   ,,r  |M.nu-titi>  an.l  .,MM„„v,.|i,i. 

'"  ,  ';■  '""'"^'  "'■  '.^1''""''  ''■^'■'-  ^'■■"  'In-  to  tl,r  l,a,.ill;H  „|  Kl,„,,|,  ,C,„-nil 
"."'  '  '■"'  '»•  ''"'''^  -iii.n,i-,„  ua-  i.,lat..,l  in  pinv  ,.„I,m,v  tr,„n  J  .„„ 
"t  ■•  'MM-  n.,„.,-.,.,|  l.v  I'a,.,,,,-..  |.V,„„  ,|u.  (im,  ,,,M.  S,a,,hvI.„..K...,H 
|.yo^.M..<  ua.  i.,|a„..l  a.  wll  a~  I!, ..ill,,.  ,,,,|,o„„.      Tvpi,,.!,]  ,„.,.i,.„iti. 

""'.""■  -:""'-^"'>   ='^~""i^"-'    i-'f'M'i„„a.i f  tl„. ,;.„„„.  M,,KTti.-ial 

';'"■' ~  "'  '■'""■  "'"••'"r  "'•'•"I-  -iNri,,^.  ,1,..  |att,T  , ,s<.  „(•  ,1,..  ,li,,,.,    ,, 

''■■■  '-H„.„  .|,„.i„.  ,1,„  ,,..,i,„|   „,•  ,,„„|.  „,„.^,,^_    ,„„    ^^._^^,_.^^|,^.    ,^__  .^^^^  •  1^^ 

""'    ''"■";'   -'I-—-,    Im.    „,av   ,.....,.,•   la.,,   in   -vaf......,,..,:  an.l 

'-"-"'l-H'>--.ln..-tl,..a„a..k„f,;,v,.,..  I!..„i„  .  |,a,  ,.,,,..,,,..1 
'■'-  ••-;•.  <n„„  wl„..l.  ,|,„  ,vplH,i,|-|,a..i||,„  .a.  i.-lat..,!.  ,„.,.,„.,-i,,,.  -iv 
-a,-  al,..,-  tlu.  ,.,.i,na,y  atta,.|<  ;  a,„l  H,.„..l,|,..^  |,„  ,,.,„,,„„|  „„„  ^^^^ 
nM^^,.v,.„v..a,.an..,.wanl.  <inin..k..  Hias  ,;.i,„.l  ,„..  l.-illi  i„  tl,..  I...,,,.. 
--w.li.n„,,|i,..,,    a.,,a,.,l   a...  a.   I,.„,  a.  ,;.„,.  „,. 

..•an„„a„,.-v,.,,,,i,i,„„  ,,,...„. li.i.n    .,n.,..ali...M„...,,.w    ,.,..! 

::  ;;'""'■, '  ;"■  "■  '-^i'-^- --  v,„„„  ,...,..„.,  „.,  ,.„„,„„, 

'  ;  Z'^'  •    ";'-'•"'    I.Ml...rtv,  an.    ,.n.r..n,l,lv   at,a..k.i.      I    hav.". 

':'■"■'■■  :'''77":'  "" "ii'i'- al.,  i„ , ,  ..i,iM,„„  ,„,  i,.,,,; 

:r::.,r'  ■'  :;''v''''^''v "■•'="-"'^'^ --'" -'•*'-- 

'•     .l..a    a,v  aua..k..,l    ,,,..-,    .n.,,,,,.„,|v  ;   al..  tl,,.   <,..,.„,.,,.    a,,.l   ,!,,, 


■'      T..n..r  r,,.ctii,....,-   is7i;    .v,„,//,>,,„,„„   ,,,•    .  „  ,    ,,      . 


l-n, 


^'mii^ 


".to 


lyriiiill)  I  iMi: 


Tlic  ili-ra-c  (it'  the  l"'ii''  iiKiy  (Mciir  ii ■  ••]•  in  -cvn-al    |):irt-   •A    \\\<- 

sk.lrtoM  at  llir  -ainc  lim-'.      O.va-iiinallv,  it    i-  r,.ntiiM.l  lu  a  -mall    ana, 

:i,„l  ina\   mm.I.t-o  inv-iliili.-ii  uitl I    injun    t..  tli.'  I".nc  ;    w  liii.'  in  niihr 

inMan.v-  |»rio-tilic  al.-.v-.-  inav  .I.a  ,  ln|,.  uilli  (Alcii-ivr  iir.Tu-i-  .,f 
ll„-  Lull.-,  aii.l  .vni  ni|,luiv  into  llw  jcint.  u  illi  all  ,,r  llir  ,-,mcninitaiit 
.laiiun--.  'I'lriniiiallnii  in  Ilir  Innuatinii  ..l'  ..\,,Mu-,-.  uliirli  ha-  I",  n 
l,„.,iliHii,'.l    r-|Hrially    l.\     rnn.li    .iilii.'iaii-,  apixar-    to    l.r   .•\<r.',|iMj;ly 

ran.  . 

'rv|.liui.l  an:.li'.ii-  of  ilir  j.>iMt-,  uliidi  may  apprav  a-  m.-nartinilar 
ur  |M.I\ailici!lar,  an.l  a-  Miiipiiiativ.  ..r  -imi.lc  iiitlamiiiat..ry  -niii-  |.nM- 
.»(■.-(  K.vii,Sln>mi'Mr.  X'.ilUmami),  liavc  liitli(Tti.  n-r.  ivcl  litllr  tliomiiL^li 
anatomic  -tudy.  Tlir  Mipjiurativ-  i,-ioii>  ajiprar  aiinoM  alwa>-  to  !„• 
the  n-uh  of  .•oini.licatini;-  H|iti.cmia.'  I'oiilirk  -  lia-.  liowcv.r,  niMii<'  a 
tliun>u;;li  ^lll<iy  of  the  .iiaiii;.-  m  tlir  i.on.-marn.w  ,  an<l  lia>  ili-covrn^.l 
.•oiidition^   -.Mii-v-iinir  tli..-r   |Mv>.ni    in    tiir    -pl.cn   an.l    tli.'    iympiiati.- 

ulaial-.      Ilc.lc-'-i-ii"-  |Mcnliaf  lai^v  c  IK.  i tainin>x  as  many  a-  'Jn  nil 

r.;,„Ml-.'oi-|.nMi.-  an.l  mon,  in  tlir  JM.nr-marn.w  of  tli..-.'  .l.'.  1  at  tlif 
liriirlil  of  til.'  .Ii-.'a-.'.  Dnrin-  .-..nval.-.-.n.v  tli.-.'  -tni.-tnn-.  iMvvion-ly 
m.niion.-.l    i.v   N,  nmann    an.l    I'.i//../.  r.>.  .'vi.l.ntly    nn.l.r-..   -n.li   tran- 

funnation     tl'iat     ll,.'     n,i     M l-,,ri.n-..i       an'    tran-t;.rnw<l    int..    '  .r-.- 

,.h,n,..-  ..f  i.i-in.nt  ..r  ma.-M-  ..f  tiiu.  .lark  -raniil.>.  Wk.'U  tk.>.' 
,vll>'an-  i-n-.'nt  in  kii-v  nnmi..r  ik.y  imiMi't  a  l,n.wnisli-n-.l  .'..Lt 
to  th,.  I„,n.-marn.w,  whi.-li  l..r-.i.t-  tor  >on..'  tim.'  after  .•..m|.l.'tc 
rfc.v.i-v   lias  tak.n   |>la.M-. 

DIGESTIVE  ORGANS. 

r>,  i;.nn.M.  t..  tt. .n.liti..n  ..f  th.   t..nL'U.'  mikI    tl...  mn.-..ns   m.inl.rano 

of  ti...  n...Mtii  an.l  ,,hai-vnx  l,a-  alPM.lv  K.rn  ma.l.^  in  tli.' .l.-.Tipti.-n  ..f 
tl,r  .rrn.  ral  -vM,i.t.m,ato|o.v.  KnrtlMi-  .•.m-i.l.rati.-n  ..f  tlii-,  .-i-.v.ally 
to  tlu.  int.n-tin-  tv,.l,.,i.l  k-i.m-  .'f  tk.'  fan..>  an.l  th.'  i.karynx.  i  '.nr.l 
t,,  l,v  I,..Mi>  an.l  .I.nn.r.  'viU  ■  .'  uiv.n  .m.l.r  th-'  -x  mi.t..n.at..l.:-y.  in 
,1„.  ;i,.:,.i  l,o,lv  tk.v  an.  v,,n-..nt..i  l.y  nain.lr.l  nl.vr-  ..f  varyin-  >ur, 
„  tin,..-  .■..nllnni',  ranlv,  how.v.r.  ..f  ;rnat  .■xt.nt,  l..,t  ..N.v...l.n^ly 
skalk.w,  an.l  .-..v.n.l  I.v  a  tlnn.  .^n,vi-l,-v..llou .  n'a.lily  .l.ta.'lM.l 
,l,.,K.si..  I-oni-  .lakn-  I.,  kav.'  ol.-,rv..l  -in.ilar  .-kano-s  ,|..wn  mt..  ik- 
It    -1 M    !,.■    m.nlioM...l    a.kliti..nallv    tkat.    a.v,,nlinir    L. 


(>o|iliaL.^u- 


not    ranl\   inv.ilvcl 


llofmami.  tk.^  nni-.iil  ir  -trn.-tnn'  ..I    tk.'  t.int;ii<'   i- 

i„     waxv     .k..,.,.n..rati..n.      Fnrtk.r   .l.tail-    xvilk    n^.r.l    to    tk.^    salivary 

glan.ls  Null   1m'  irivn   in   .■..nn.rti..n  uitk  tk.'  analy-i-  ..f  tl...  n..l.v..lnal 

•  Kl..TT,w.v.r,  l>,.,f~.l..  .I.v/,.  r  /,/,„.  .1/,./.  iss'...  IM.  xliv. 
:  l-;,-./,..,r  .V  .1/v/,,...   1S7-J,   li.l    InI- 


mi^itk^^i^m 


m^»i}h^sr^::^^iiii- 


r  I  riiDi.iK.  y. 


!i| 


-ytiiin.Mii-.       At    tlii-    |,l;i,v  it  uill  (inly  I..-  .iicntiotK.I  ilm  tlicv  miv  .,li,n 

tnliml    ,  mIiII-mmI    ulicll    .li.ltll    ll.l-    |;lk,.,|    |,l;|,v  ;it    ;||l    r.||-|v    -t.lL'.'    «i'    tllr   ,|i-- 

1.1-.  I'li'y  til.  II  ,i|.|HMr  liriMcr  ili:iii  iiunniil,  il.irk.r,  ,|i  ..,],, nd  Im-.ium- 
'-''  >'llnu  ,,r  .rll(,ui~li  i-mI,  mikI  on  iiiiiT,,.,-..|iir  .AMiiiiiiMtinn  tli.v 
cxliiliil,  ill  a.l.ljliuii  t,,  rvhl,  iir(-  (if  !iy|MivMii,i,  ,l,,ii,K-  MN.IIiii^r  ,,|-  ,||,. 
;;l.iii(lili.ir  evil-. 

Tlir    -loMlMcli    ;illi|    til.'  ll|>|>rr  |url    ..fill.,    int. -ill cnii.v  ;|  >||l,.,|-,i;. 

IKlt.'   |ll.l.v   ill     ivl:iti.,ll    t..   til.'    IVMI.-lill.l.T    ..(■    til.-    -Ill, ill     illt.Mill..,   til.-    l;iro,. 

""'-''I"-  ■'ii'l  'li''  iv.'liiiii,  with  ivu-inl  to  iluir  ,iii;il.,iiiic  l.-i,,,,-. 
Kv.ii    th.>    .•Miii.r    ..liMTvcr-    iiii.i    nil    .,f    III..-.,     uji.,     i;,||.,„,,|     ,1,,.,,, 

iii.iiti.Pii  the  .Mviinvncc  of  .lct;iiliiii(iit  :iii.l  |mii.-t;itr  ivilii.—   ..f  || m-- 

"'"■   "I'l' ^   m.iiil.r ,  jui-ti.iil;irly    in    tlif   viciiiiiy   ..f  tli.'   |.yl.,ni-,  at 

times    witii    iiiiiii..ri.us    .Mi|«rli.i.il    .i-.-Lm-.    or    a    iii,nk..|    iii:iiMiiii!l.it.-,l 
M|.|.c.ir:iii.v.        L.,iiis     liM<i     ;iliv,i.|y    -li.iui,     tli:it     tlio.'     loi.m-     |v|.n>cilt 
Motliin-  .It   ."ll  >|Kviti.-.       n.vniti.in  .,1'  tli.^  .-..plia-us  aii.l  -tuina.li  ...va- 
-iniialjy  ......iMx     Mit,.||,.||i  I,;,..  r.|..irt..|  mi.Ii  a  ca-.'  aii.l  ivvI.u.kI  -.v.ral 

olii.i-s.  1m-,,i„  n.Mi..  .,f  tli.-s<.  haw  ty|ilM.i.|-l.acilli  I...11  i^olat.Mi.  an.!  tlirv 
•  nv  i.r.ilial.ly  .Iin.  to  a  .-^M-oii.lary  i.roccss.  Stri.tnro  of  the  ^..^liajrir- 
rollouiiii:  tyi.h,,!.!  r,.v..r  tank  ..ci.,-.  S,,.!,  ,,,s(.s  have  L.tii  tv|..,ii,..| 
\>y  I'arkanI/  .Mit<.|i.II,'  an<l  otiuTs.  I'rohal.ly  tln>  .•on.liti.m  i..  ,in..  to 
a  .i.atri/ati.m  .,f  th,.  >,voii,lary  i.i.v,-.  The  att.Mnpts  of  C.mil  '  an.l 
(■haMti;ir.|  ■  t..  .-tal-li-h  a  iN.iiliar  ty|>h.,i.l  air.rti.m  ..f  tii..  .-t.i.Ma<.h  in  the 
''"■■ii  .,f  f.M^al  ac.Miniiilati.,n  ..f  ly.n|.hati..  .■I,.ni.nts   in  tli.'  ..iii,..,n.   ,„..„,- 

'"'""■  >■'■'    ••'•'I""-'-*  ••oitoIm, rati. III.       In  1h,.  ,1 j.,,mn   aU.  at   tini..s,  i„ 

my  .•\|,.Ti.M.v  1..SS  .•oniiiionly  than  in  tli.^  .-tomaiOi,  -w.llinir  an.l  i'..l- 
Tir-  .if  th..  niii..oiis  in.inl.ran,.  a.v  pn-.m.  In  .,„,.  Jn-tan.v  I  .,l„.,-v„l 
.Hip..rli..,al  .ro-ions.  Sp.vif,..  h.-i.ins  .if  this  ,Hirti.in  .if  tli..  intotii...  have 
llk.wis..  n..t  as  yet  l.(<.n  .lciii..,i-trat.'<l  with  .■crtaiiiiv. 

Of  .n.irni.ius  ini|Hirtan<v  an.l  .loiiiinatinjr  tlir  intiiv  pictinv  „f  th.- 
"..at.iiny  of  typh.ii.l  fewr,  liouwrr,  ar,.  tli..  L.-ions  pn.-.nt  in  tli.  tni.hll,. 
a"'l  lou.r  iHirti.ins  of  th..  i,.t..s,in,.,  from  ,|„.  1,,,,,,.  ,|,i,,i  „,•  ,|„.  j,  •,„„„„ 
'l"wnwar,i.  I5,.f.,r,.  ,.nt..rin-  np.in  a  .l.tai!..!  ...in-i.l.Tation  of '  th,..,.. 
s"Mi,  i,,.„..ra|  -tat.m.ntsas,.,  th,.  ai.atonii..  an.l  t.i|«.^r,.aphi,.  ,„„,|i,i„n. 
'"ay  \n-  nia.i...  In  a,...or,lan,.,.  with  th,.  .■oiuliti.i.i-  pr,.s,.nt  t,.war,l  ti„. 
-I'-  "t  lih.,tli,.  I,.„|i,.s  .if  tiio-,.  ,i,.,„l  .,(•  „.,,|,„i.,  ,;,,.„,.  ,V..,,iu.„,lv  ..vhiliit 
'"'""'■-ni.  rins  i,  |il<,.|v  to  l„.  ,.-,K.,.iallv  mark,.,!  an,l  uniform  in  ,lisiri- 
;■""■•"  in  all  part,  of  th..  .li^n-tiv..  till,,,  .nly  wli..,,  ,.xt,.nsiv,.  ,H.rit.initis 
'■-  |>r.s,.nt.  \\  h.n  this  i-  ahscnt,  th..  ,li>t,ntion  inv.ilv.s  pr.ffabiy  the 
|./.7.„,  //„y,/.,„,  //,,,^,   /j.,,„^  ^.,,1   ^.j|.  J  ^,^.^^    ^^  ^  ^j  ^^^     ^^^^^ 

*  '■'"■    l',hl.,„i.  ,/,'^  S,;.   ,„,,/..   1K80. 


It 


*!:l'._  ■'■•".if 


92 


ivriioih  1 1  vin. 


%\] 


l.ilLir  iiilr-liric,  ;ill(l  l;c  III  r:ill\  lli<  -iii:ill  ilili-llln  in  |i --  iliul'iS'.  \\  Ik  II 
llii'  ioImii  i.  111111-11:111^  lull.:  <i|' oi'i'iijiii  ~  :iii  iiliin  inii:il  -It  ii:it  |i  ill,  i  ii'  ixjiiliit- 
;il\|iii:il  111' ill'^ilin  III  III  il--  iii|i\  iililliiili-.  till  -Mi:ill  ililr-lilir  ina\  lir 
I'liliriU     I'liMi'i'il    li\     il.        riir    liiwi  r    |Hiilii'ii    III'  llir    ill  iiin    \~   ullin    nl 

ll.illll.ll    i:llil'i  r,    iif    iVill     iii||lr:lrli  i|.  I'llr     M|i|Hr     |Killiiili-     III     lllr     -lIKlll 

inli -liiii  iilti  11  I  \liiiiil  iiiiiiii'iMli'  111  I  \  111  iii:irkril  irnii  iiri-iii.  (iriirnilly, 
1,11  1  All  rii:il  iii-|Hiiiiiii  III'  llir  ili'iiiii,  r-iMri;iliN  il-  'in\ i  r  |ii>i'liiiii-,  ihirk 
linr:ir  -IK'I-  r:ill  lir  -rill  i'|i|Mi-i|i'  llir  ,il  lailllili  III  "I'  llir  II  n -i  lllil'N  .  <  )|l 
|i:il|i:ili.ill  llii-i  I  \liiliil  ;i  ijili-ir  I'l  i|i-i-Irllry  tli;lll  llir  liliuillnlir  nl'  lllr 
illlr-lill:ll  Willi,  .inil,  :i-  will  !"■  ili-i  |i  i-ii|  nil  ii|>illillL;  llir  illti-l  illi-,  llir\ 
(•iii'l(-|Miiii|  111  llir  -|iiiilir  I\|iliiiiil  iiilr-lili:il  li-imi-.  'I'lii-  cuinjil lull  i- 
(li'|ii  iiiji'iil  ii{iiiii  :i  |H'i'iilial'  iiil1;iiiiiii:iliii'\  li\  |ii  r|il,'i-ia  ul  tin  l\  iii|iliiiii| 
.-inirinii-,  wliirli,  in  ari-nrijaiii-r  wiili  it-  -cat  in  lli.'  -mall  nr  llic  iaitri' 
iiiti-tiiir,    miiir-   a-    li\  |ii  r|pla-ia    nl     l'i\ri-    pal' in-   nr  nl     llic   -nlitary 

tnllii'ii'-, 

liri  liiiiiicau  «a.-  prnlialilv  llic  tii>l  wlm  ilirrilfil  allciilinii  riii|iliiilic;iily 
ami  iiili-llijii;tl\  111  llir  l\|iiiiiiii  Ic^inii  nf  llu-  inlisliiic,  lie  ciiii.-iiliTril  it 
,-|n'i  ilir,  allliiiiiL'li  lie  cuiiiiiarcil  it  ^^illl  llic  v:;ri(ili)u.-  Ir>iiiii  nt'  tlic  «'Xliiiial 
iiili'LTiiiiniil.  .^-iinihir  n|viiiii)iiri  liiivc  lit-cii  i',\|irfs.-cil  liv  nilur  nliM-rv  ci- nt 
llic  ^alln•  ami  it'  a  later  in-rinil.  In  llic  ccli'liratcil  Imnk  nl'  Lmii:^,  linwixi  r, 
i-|i-i-iallv  ill  llir  M'cniiil  I'lliiioii,  tin-  iiili-liiial  l(■^illll  i>  cltarly  rccii;jiii/ril 
ami    ill    lin-   main    lliiiri)ii;:lily  diwrilicil. 

Ill  lllr  ilrtailrii  >  lr-rl'i|  it  ii  ill  nf  lllr  typliniil  illtr-tilial  ji-inll  -rMTai 
-ta^r-  ai'r  a|(|ii'n|iriatiiv  rrciinni/nl  :  1,  tlir  -tat;r  nl'  liy|irriiiii.i  ;  'J,  lliat 
nf  iiiiiliillai-\  iiitillratinii  ;  ."..  tliat  nf  iiri-rnlir  ilc-tnirlinii  ami  iilrrratinii  ; 
ami     I,  tli.it    nl'  riratri/atiiiM,       In   ;:rnrral    tlir-r  anatninir   -ta^ir-   I'un-r- 

-|lnm|  willi  rntalll  |liirlliill>  nl'  tilr  ilinirai  rnlir-r,  it  -llnlllii,  lliiwrvrr, 
lir     linnir     ill     niimi      lliat      tllr     illtr-tilial      Ir-inn     (Im-     lint      (!rviln|)     ami 

rMrmI  -iiiiiiltamiiii-lv  ami  iiniliiriiily,  Imt  ratlirv  in  -la:;!-,  nllrii  ili— 
triliiitnl  nvcr  a  rnii-iilrralilr  |iri'jiiil  nf  tiinr,  ami  il  likrwi-r  uiidrr- 
irnr-    iiiMilniinii    ill    a    cnrrr-ii iiii^    iiiaiimr.       ilir    Inwrr    |((irliiiii    nl' 

tllr  ilrlllil  ami  tlir  liriiililinrllnnil  nt'  tllr  ilrncrial  \alvc  air  jrcllrniliy 
altarkril  rarlii-t.  <  (I'liii  tlir  im|irr— inn  i-  rrratnl  a>  if"  tlir  |(rnrr-> 
rxtrmlrii    i;niiiuall\-   nr    ill    -ta-r-    friilll    tlli-    |)niiil,        I'lllt     il'   it     lir    takrll 

iiitn  rnn-iiiri'.itinii   tliat  rrla|i-(-  ,iml  n  rrmlr-rriirr-  nl'  ty]itiniil    Irvcr  arc 

attriiiiril   with   rrlirWdl   illMiKrliirlil   nf   lllr  illtr-tilial    lllllrnll-   liirllll irailr, 

it    ran    lir    limlrr-t 1    tll.ll     li\'    lin    iiirail-    llirrly     tllr    \al'inll-    rtaL'rs    nl 

tlir  -prrilir  Ir-inll,  llalllrlv,  iiililt  rat  inli,  -Inll^llillLr.  Iilrrratinii,  ami  r\Cll 
i-nlll|ilrlr  rira  I  ri/at  i<  ill,  ran  lir  -Imlirll  ill  tllr  -aillr  |)nrtinll  nl  tllr 
illtr-linr, 

Tlir  lif-i  >tai;r,  that  nl'  |i\  pr,-riiiia  nl'  tlir  iiiti-liiial  niiirnii-  iiinii- 
lifailr,     whirll     prnlialiU     nrnipir-     tllr     I  iri;iiinill<_    nl'    tllr     llr-t     Wrck.     ill 


/'I  I  lI'llJK,)- 


93 


'~"'^""'    '":''■' '■"■"    ""— i'-.u.-M^,  H ,n.|..,.-,.,..|    i„,|..,.i|    „„ 

: ;'    ':'    "-•^'■•■■■'i"^    '--iu     ui.l .1,   „,,,..,,„„n,v     i;„-   :,„:n.^„i.. 

';"'~"^^"' -'"'"■''■''■        I^.U..H,-U   .,.,1    T,„,H-..MM    l,i.|„.nl     ,1,.,,     .., 

Ilii^  IMH,.  l,x|,..,vMM.,  ..I  I',;,.,'-  |,.t,l,.-an.|  (I,..  -„|i,an  tolli,!.,  ,„,,,,, 
a-  ll,,.  I,,nn.,.,„r  ,,r  ,M...lMll;,rv  i„lilin.ii..,i  ;  Cuniil  ^n.l  l.-M.ivi.,-  ,|  , 
■I.H.M  ,.,  I,.V,.  ,MM,i..  -in„lM.„l,-,.,.vanuM-.  In  M,-.-,>.  „fM.i..i,|..  1  |,,v,. 
..l-rs...|  „,  .1,..  ,Mi,MI,.  nCI,,.  li,M   u,.,k  .I,..m,Im„,.,„  an.l   ,uM.-k..,|  In,.,,- 

'"'""'    ''"■   '"" -    >M-.Ml,nM,.,,f  ,|„.   ,.,..•„„,,. I,-  ..lia.vnt    |H,ni,,i..  ,,(■ 

''"■  ''" •  •""'    ''"■   •■•''"■'•  "'■'!'  -li^l"  -".llin.  oC  tlH.;,.„,i„Ml..:M„l  -..li- 

larv  tull,,!,.,.      Tl,..  f,v,|Mr„.v.  iIm-  ,m.„,,  .-umI  tl„.  .I,.|,il,  ,,C  ,|,,-,.  ,i„,,.., 
I.<m.    ,M    tl,,.    i.„livi,|„al    ,;,-.,  „|,,,1,,,    ,„r.v  nnv  Im.  umm.!.,,..  u  ImiImt  in 

;■':"'  "'  ""-'•''"'■"'  ^ -'i^-  •M'''"i''   '•' ^'■''  'l"v  -I-  n...  t:iv..  ri-..  ,.,  t„nl,..r 

N'HOM-,  ul,,.,!,..,-    ,„   ,.,,,MiM  VMri,.ti....,r  tl,..  ,li.,,„.    tl,,.  .liir,,-..  ,.M,Mnlnl 

""'■ -    '■'     ''"■    "'"-'i'"'     ■•'■M,'lu.>  .•.,K.,.i:,|K     l,id.     .^VMlr.    uC    i,„,,„i„ 

■■'<■'■    all     M"-"""-    thai    await     a>.>NV,..-     I,a>,..|     n|H,„    ,„.„•..    r.uu-h^- 
<.\|H'ii,.ni.(.. 

With  tl,..  l,..,i.,.,i„L'  ,.)■  tl,.. „,!  „,,!,,  i„  ,„,.  ,,.  ,..„,„  ,„,,|,,,,,|^  .,, 

•I"<>"l"f   tl,..   r„M.  „,..,l„ll:„-v  inliitfati..,,  ,,!,,,.   ,,,„,.    ,,,„|„,,|,,  „i,|,  .^ 
''"'■ -  "'    ''"■  '""■"■'•  l'y|..T..>„ia  a.,.1  >w,.||i„.„f  ,1,..  i,„..Mi„al  ,„„.■.■„. 

'";■'"''"""■■       '"    -'■"'■'•^''-     '''•.^'■'■■-    i'-'"l"-    ■■>\<V'----    -..    Im.    ^ ul,at    i„ 

•Miva,,,.,.   ,.t    ,!„.    „.li,a,-v    i;,lli,.|..,    „itl,    ,•.,,.„•.!    „.    ,|„.   ,.v„|,„i„„   „,•  ,|,„ 
|-n-.-~.       Nut    fatvlv    ,.,„in.   ..|,a„,..,    af.   .,l...rv..|    „„i,;,n.,lv    i„    1„.,|, 
"'".■    inhltt-at,,,,,    „l'    ,|„.    .,|i,a,.v    Clii..!..,    ,,,,..,.li„,.    ,|,at    i.f    IVv.t's 
|>.-,i.l,cs   .Ices   not   a|.|...ar   t..   I,..   ('r...|,i,.nt. 

In  th-if  (;„•„,  a„.l  -it„ati,.n.  tl,..  ty|.l,.,i,|  j,.;,,,,,  „at,in,Ilv  ...rn- 
i>..n,i  ,„  J,..,,.,,,,!  „,  ,|,,ir  a.,at,.„,i..  -„i,.tn.t,„„.  Tl,..v  atv  ..^al  wit). 
';»'"■  l.m-,t,„l„.al  axi.  .„.-n..,K„„|i„^,  t..  that  ..f  ,|,..  i„„..,i,„.  ,,,, 
>m.a.,.i  ,,f,„..,,,ally  i„  that  |H.ni„„  ,.f  th.  i„t...,i„a|  ,..„al  .,p,'..„it,. 
'I-  .„.-..Mt..f,..  ,ma..|,„„.,„,  a„.l  ^,.,„.„.||y  ap,M.ar  as  .hat-plv  ..i.v,.,,,- 
-nl"<l.  ,l,~k-.l,ap..,i,  ,.v<.„  (•„„,.,_,,,,„.,,  ,;,n,„,i..„s  ^vith  ..v",.fl,an.M„.r 
-rMf;:,n>.  At  (ir^t  ^.vatly  n,!,!..,,...!.  tl„.y  M.I,s..,,,„.„,]v  a..,,.if,.  a  .^^^^,1^ 
rr.l„r,  at  tl,..  lM.;,i„„i„.  „f  ..xC.li,,,-,,,,  ,  ^.ravish-;-..ll..w  n,|.„,  '  Tho 
Mirfa....  ,,»  tl,..  |.a,..|,..s.  wl,i,.|,  n-ay  pf.,i...t  fn.tn  .1  in  r,  .,r  ,.v..„  „p  ,..  H 
"""•   ''I'-v.   tlu.    i,„...,tit.a]    ,„,.....„.    „u.n,l„-a,u..    i>    at    tin...>    M„....tl,     at 

•-ti'.r  t>„,..,  ,ii.i„iv  ,,^,„„,,, ,„.  „^.,.„  „„„„„,,^„  ,„„,,,,^,^    ,,,,^^,^^_  .^.^;^^___ 

;'nt„.s  an.  .i„„l,tl,..,  ,hu.  t..  ,1,..  (art  that  ..,„„.  tolIi,.l,.s  ..„„.,,•„.  int..;!,,, 

'""""""  "'    •'"■   I'.'f'-I'  l'='V'.  >M.t  y..t  l,..,..„„ „,pl,...,iv  ,.„„fl„..nt  ..r   at 

I' .^t,  ar..  ,>„t  >w„|l,.„  ,.,  ,i„,  i.,v,,|  „,•  t|„.  s.irr..,„Mli,.;r  ,iss,„.s.      Tl,..  ..'.„- 
>i~I..n,.y,  th,.  .|,.jr,v,.  „(•  ir,tiltn,ti„„,  aii.i  thr  .l,.ptl,   t„  wl,i,.h  th,.v  ..M,.„,| 
a.v  ..v,n.„„.|y  varial.l,.   i„  ,lin;.r,.„t   .-as-.s.      Kv..„   at    ,l„.   pn.<,:„t   ti„„. 
'••■'"<l'   '•lM.i..,a„san.  i„  tl„.  hai.it  .,f  n.akii,^^  ,,,r,a,„  ,|isti,„.ti.,ns   i„  this 


I 


:ii^im^:PiimiLi^m^m 


MICROCOPY    RESOLUTION    TEST    CHART 

ANSI  and  ISO  TEST  CHART  No    2 


1.0   i^"-  i^ 

=^=       1^  m     12.2 


I.I      t 


2.0 
1.8 


1.25 


1.4 


1.6 


A     -APPLIED  IIVHGE     Inc 


Rochester,    New    ror-n  '  »609        USA 

(716)   *e2  -  0500  -  Pf^ofie 
(716)   :ea-  5989  -Fo« 


m-^^m^m 


94 


TYrii'iiii  I  i:\i:i!. 


-iiicl.       Acccirililiir  to  tlicm,  the  M)tt    ii-lclio  :iii(l  the   liiinl    |i;it(lus  iif 


I. 


t[u~  plav  an    iiii|Hirt 


aiil  /I'A    tliat  i>  not  ijuitf  cuniin'iiirn^ililc  tr 


irc-rnt    iHiuit    (il    view. 


11 


ir  Muchillaiv   -u(lhn<;  i-  iiv  no  incan-;  aiuii 


luavs  ciinCnicd  t"  llic  limits 


>f    lllc    1 


latclii-. 


At  lime-  the  intilli'atinn    cMfnil-    IicmmmI  llicni    to   tin 


an|airnt    nMK'im-    nicinliranc. 


I 


nilcr   -iH-li   circnni-tancc-   >i\rr 


il    inlil- 


ti-atcil    |iatcli(-    niav    cualc-cf,    and,    in    ccin-i'iincin'c,    |i(cnliarly    -liajicd 


liialrd  lni'niati(in~  ni 


tlir  dinriiiin  .it'llic  a\i-  dt'  the  Imwrl  nia\'  nl'tcu 


i-iilt.       Ill    otiicr  ca-c-.  cm  the  ntliri-    liand.  thr   pali-iii  -   arc  nnly  parlly 
K\d    in    inlilli'atiiin.       (icmrallv,  tl alc-ccncc   of  the    inllllralc<l 


1' 


,1,1     ..(>(■( 


in>  |)rcl'ci'al)lv  and  nm-i    cxtcn^ix cly   in   the    lo\Mi-inip>t    pi 


tidii-      .    tile   ilcinn   just   almvc   iln'   il(MK'f("al  valvi'  and   in   llif  adjacent 


1" 


liiin~  lit'  the  crcnni. 

Tlir  intiltraiiiin  i.tthc  Militai'x'  tiiilidc-  ciinnnoidv  pfcscnt  in  additi 


t'.    IlIC    -\\c 


lin^  ct'thc  jiatclu-.  and  cxhiliitir.j.''  in  ditVcrcnt  ca>c-  the  must 


d  di-trilmli 
ll 


ihrnniihiint  the  1; 


tV'jf    nitestnie.  and   at  tniic-  ex 


tend- 


niLT  nilo  the  ~ii:niiiiil    lie 


tiirniation 


\nre  and   e\  i  n    intn  the  reetum,  trivcs  n-c  ti    tiio 


it'  rciundi-h.  era\i~h- 
le<i    II 


reil   ill'   ei'ca 


tlv  reddened   eicvatiens,  t'r 


<|nenil\'  -nrnmnilnl    liy  a   e-;iri;in(i   i 


if  ve-el-.      Tl 


liriijeet    ali(i\('   the 


mneiins  meniln'aiie  In  the  -i/e  i 


if  a  ))' 


and  lafi;cr.  and,  like  the  patch 


i,..t    rai-cK'  cxhiliit    an    cxtcusiiin  (if  the   intiltratinn    licynnd    the  urieinal 
limit-  of  the  follicle-.      'Idicy  may  then  develop  into  lariic  fnii'^ns— liape<l 


innations  np  to  thfci'-ip 


rtel's  ot'  an  inch  in  diamelef.       W'itli  the  co 


iiieneenient   ot'  involution    thev    eciici-alh   as.-nmc  a  yellowi.-h   (ojor.  ami 


then.  I 


-pceialK    il' ot' moderate  -i/c.  ac(|nire  a  pi 


stul 


ustiilar  aiiiicaranec 


I'l" 


'I'l 


cuiitinnan f  niidnllary  -welling,  in    Imth    the  aLiininatc   and    the   ,-oli- 

t:\v\-  t'ollicle-.  i-  lu'iet'.  All'cadv  in  the  second  week,  nt'ten  at  it-  l)et;in- 
iiinii',  iinohition  -et-  in.  (  a-e-  of  connnencini:  exti.liation  as  early  as 
the  tiftli  and  the  -i\lh  dav  ot'  the  di-ea- 


e    have    been  recori 


le<l.       I 


I  con- 


tra-t  wnh 


the-e.  ii    i-   trnc.  oh-i  rvations   also  ha\e  lieen    made  m  which 


the    intiltraiion-   exhiliiled  no  sieii  of  commcneini:-  <lisintei:r;itioii    at    the 


end  ot    tl 

the    detel 


le    -ecollil    Wi-r 


It 


inav    lie    oli|e( 


ted  to  these    -tatemciit-   that 


ilioii  ot'  the   exact    da\   of  the   disea-e  i-  dit'i<-nlt,  Imt.  a-  a 


re-lilt  o|'  iinei|iii\  ocal    per-onal    oli-er\  ation. 


I     liel 


live  that   tlie\-  are  wel 


lonii' 


liiMilniion  of  tlie  medullary  -welling:  may  in  i^viieral  he  liroii).dit 
:,|„,nl  ill  one  of  two  way- :  eiihei'  in  the  t'orin  of  actual  ali-orptioii  of 
the  palholii.jic  proijiic'l-.  or.  a-  i-  hy  far  the  more  common  method,  in  the 
form  of  necro-i-.  with  -nli-ci|iient  exfoliation  and  the  formali<in  ot'  cor- 
iv-pondiiii.!-  nicer-.  I'xitli  ot'  tiii-e  varieties  of  iiuoliiiion  are  frei|iieiitly 
o!i-c  ived   in  the  -aiile    iilte-tine;    e\eii   in    the  -aine  patch,  -iinplc  ali-orp- 


1'MII()I.0(;Y. 


!».") 


tinii    ijiiitc    coriiiiKinlv    (icciiiv 


II'  it    III'   n  inrinliciiil,  a~   I 
tile  l(-i(in>    in  the  siiiic    l> 


111    a-MicialidTi    with    iilccnit 


ivc    |inicc>,,. 


ia>    hccii    iiKJiratcd,  lliat  tli 


(■  \ai'iMiis  staifc-  lit" 


Miily  j.rciici-a||\   cxliiliit  var 


"""  ••iii'l  iiivuliii Mcrdnliiii:  tipilic  |.(.i-iioii  oCtli,.  1 

I"'  '"iiipivlifnd.d  tliat    (.cca-idiially  aliii.,-t  al!  of  tl 
iIi-cimImmI   iiiay  lie   (ilp-ci-\c(l  at  tl 


illll-     ;rl-;|,l,,^    ,,(•    ,.vi,|, 


Hiwvl  in\n|vc(|,  ii 


I'aii 


H'  aiiatoiiilc    nine  SMS 


-|"'<'t    t.i    iiidliratiiiii,  witli    rcp-ard 


ic  slliic  till).'   ill  the  same    l.i.wri.      .] 


ll-t 


the    I- 


■Ml'  -   |>atcli('>  arc  p'licr 


l-llirlr-.         With     ,',,( 

li'aliMii-  that  iii-a|i|>t'ai'  l>\  ah~(irpti 


til    r.'u-r'|..^iv(.   altcnitiiiii-,    mi 
hat    ill   aiKaiii'c  of  flic  Military 

rrcllCC     to     the      I'C^rl'civ,.    ,'l|anjr,.<     ill    ,l,.t,,i|^    t|„.    j„f||'. 


lli\'    MllllCW 


yellow    di-coloi-ati 


lull,    ami    then    pronic- 


ri'Mti'l' 


III  ui'iientlly  at  fir-t  |ii'cM'iit  a  -ri-avish- 
i\ely   ('olla|)M',    at    iii'si    at    tiic 


ami  from  this  point  toward  the  iieripherv.      J,,  tl 


111  iiecroH-.  the  (ir,t  indieatioii  of  this  | 


K'  jiart-:  .iiv 


lived 


111'"  ai 


id    --wellini;-    of   the    ti~SMe,     freolicntl 


>l''i<'css  I sists  III  a  eert; 


tllliletaelioii    of   th,.    s||n-,,|,|||| 


|iicntly    with    rcaetivc   ledi 


nil  .|ion;ri- 


d 


IMI 


iile-  then  ai'i|iiii'( 


iiiLT    inneoiis    liK'inhi-aiic.      The   patches  and 


l-h-\ellow 


•ayish-vcllow,  iic\t  a  pale-y.'llow  or  di 


eoioi',  and   Mion 


I'eoiiie   from   dirt\-   hrowiii-l 


'ilive  jmrii  (nun    imhihiri if  the  cont 


ity  o'niy- 
I   <rreeii   to  dark 


liile 


that    the   iiite-tine    in 


ents    of  th,.    intestines, 


csiieciallv 


"ii-ervei-  a   mo~t    rcmarkaiil 


<'iili-c.piei)ee    prcMiits    to  the    inexperienced 


A~   to  tli 


c  a|ipear;iiicc, 


e    imiiiiijiatc    can- 


c    ot    t 


'liiiiion  that  it  is  a  tlirii;  of  ca- 


ll''  iiecro-is,    Vi,.,.| 


<'lllo~]~  ;    w 


lull'  Orth   thinks   that  it  is 


'Mtion  much  like  tlcit 


Kiw    was   ot'  tlu 
occiirriii;,''  in  tiil)er- 


cxerti'd  on   the  IiIoimI-vcss,.], 

I~-      III  thi-  connect 


III  eoiise. 


till 


I-  an  anemic  mcrosis  due  to  pre>s„,.,, 
icMce  of  the  jrn.;,t   hyiMi-plasia  of 


ion   the  Work   of  M 


iNiiry     on  the   hisioh 


'lian^c.  nitvphoM  ,;...„.  ,1|„„|,,  I...  ,„„„,.„„„,        „.;„„„„,,„,,„  ,,,^.,_  ,[;,,, 


f'l  till'  action  of 


litcration  of  cndothcli 


a  toxin  prodiiciKl  l,v    the  tvplioid-l 


r 


lerc  IS  a  pro 


d  the  -ucllinL'  'if  the  iiitc-tinal 


ph'iid-liacilhis.  tl 
irc   phatrocytic  in  character 


til  their   toriiiatioii.      'j' 


lymphoid  ti-sii,.  i,  ,||„,  .,1 


most  ciitireh 


Mills   am 


"'  ii''''i-oM-,  he  think-,  is  d 


'I   ••ainllarie-    li\    til 


lie    to  occlii-ioii  of   tl 


'''i^viicratioii  of  |.liai:oc 

^'"'•K.        He    dcMrihes 

.inland-   and    the    -pl,,.|i. 

'i'he    procc-   ,,)•  ,,^t; 


I'liiiiiis    thmmlii    which   owe    t|, 


■tic  cells    licnc-ith    tl 


cir  ori;:iii   ti 
M'  liniiiLT  cndothcliiiiii  of  th, 


■  I    similar   jmiciiss  occnr 


I'liiLT    111    the    iiieM'iiteri 


lialion    IS    i-ai'cl 


<i<cp  at    al 


ii'it  thrown  o(V 


l';i'-|-  'il    'IMC    patch   of  l',.yn-.  M,  that   cm'1 


pially   advaiK'cd    and    eipialK 


\'   cijiialh 


Huall 


ir  particl 


'"  '""'   I ''•      This   take-    III 


e-.    Ill   one   -Itliatii 


jiiace.  a-   a 


lars  arc  jjfcneral 
rule,  in    1: 


d'iplv.       |i 
area-,  in  ,■,,! 


it'lii'-.    ill    which    h, 
l-'''pleliccof  ,.xi;,li:iti 


more  '-iiperdciallv  and  in  aimtl 
'tuieii   still   slomd 


II.  are  already  present, 


ii'irer  or 

icr  mor(. 

liiitr  jiortioiis   nlceiiited 


L'eiiei-allv  acnnirc 


•/■"•■.    Kr,K    .\/,./.. 


%^tSf 


-m 


I 


I3S 


^'    '  ■  I   '• 


■i-r :., 


fl« 


ryriinin  1 1  i  /.v; 


I 


f^H 


a  jifciiliMf  iri-cuular  M|i|M:ir:iiicc.  'I'lii-c  li;i\i'  Ihtm  il(-ii:iiat(il  1)1mc|II(-^ 
iraiil'ivf-  lp\  l.itiii-..  'I'lic  nil. IT  I'Miv  cxtnlialiiiii  cl'ilir  -liiii^ili-  a-  a  wlmlc 
lakr-  |ilaii'  |irttiraM\  in  llii-  cMivnicly  ilcn-c  ai'ca-  ami  in  liid-c  ;)i-(- 
-(■iilini:-  <l(c|)   intillniliiiii    (|ilai|nf-   diin-i. 

'I'lif  mIci'T-  Ic't'l  afli'T  cxtoliaticMi  (if  llii'  -lnuuli- attain  a  saiialili-  ilrptli 
in  accm-d  nrc  u  itii  tlic  cxtrnl  nt'llic  antciMilrnt  intilti-aticm.  At  tinic-tluy 
.-cafcclv  iicnctfatr  the  nni('iiii>  nuiiiiiranr  ;  at  uiIiit  liino  tlicy  cNtciid 
diiwii  til  tile  nni-cnlaf  cnat  <ii'  cmii  dc-tiny  a  lavcf  llicri'nl';  and  at  -till 
iitlicf  linio  till'  tiitifc  inii-cnlar  cnat  i-  dc-lfnyid.  mi  tlial  tln'  nlrrf 
cNtrnd-  111  tlic  ^cinn-  la\cr.  l'-\rn  tlii-  i-  dftcn  Lii'catly  tliinncd,  cv  en 
dii-,-,ii  t..  a  d.'lifatc  incnilii-anc.  'I'lic  niai'uin- nt' llir  iilici- afc -liai'|i.  and, 
]iaftic'nlaii\  at  tic  lirtiiiniini;',  ai'c  >tf(|i  in  ciinMiiiicncc  nf  -till-rNi-tinii 
iiililtintiiin  in  llir  niiu;lil"ii'lii«id  ;  tlic  latlif.  ImwcM  r.  Hinn  di-a|i|i('ai>. 
'I'hc  cduv-  aif  Hvncfally  little,  it' at  all.  drtailicd.  'I'lii'  lia.-i'  nf  the  iili-cf 
])rc>ciit>  a  iniiic  uf  lc->  dafk-fcd  a|)|Haranrc  -lidi'tly  alter  cNtiiliatiun  lia> 
lieen  ciiiniiletctl,  anil  it  i-  nlten  -till  ruNtfed  in  \ari(in-  ])larr-  witli  -mall 
reniain>  nt'  .-Imijili-.  The  nldef  ]iii|-ti(in-  Mum  e\liiliit  a  -laty  di-inlina- 
timi.  The  inte-iiiial  iileiT>  M->nnie  the  tiifin  .it'th.  |i|-e\  imi-  ana- nt' 
intilti-.itiiiii  I'lilv  in  mi  tar  a>  tlit-e  have  nut  iindei-i;iiiie  in\  iihiti.iii  hy 
.-iinple  ali-iii'|itiiin.  It  i-  wdfthy  nt'  inentimi  that  lai-j;c  ednlliieiil  nleer- 
iiiav  fiii-ni  iti  place  of  the  ednthieiit  |iatel»>.  and  that  the-<'  afe  imi-t 
t"fei|llelillv  situated  in  the  nei;;hlMirh(i(id  nt'  the  ileneeeal  valve  and  the 
InWennnst     )Hiftinn   nl'    the    ileUlH. 

The  iileeiN  fonltiiiL^  fi-iiin  the  Militafy  fnllieles  irenenilly  Mttaiii  a  >m' 
fl-mn  that  nf  a  lentil  nr  a  [lea  ii|i  In  llireeM|Mafteiv  nf  an  inch  in  diameter. 
The  Iniifritudinal  axe-  nf  the  laipr  nleer-  ate  imt  i-ai(  ly  directly  tfaii>- 
veise  to  the  axi-  nf  the  inte-tine.  In  the  fare  caM's  in  which  a  iinmher 
(if  ulcers  lie  cln-e  tnjrethcr.  eveii  aniudar  ulcer-  with    -ul)M(|Ucut  stennsi> 

(if  the   lari:!'    intestine    ma\-    'ur.        I-"in'tlier  exten-inu    nf  the    tyjilmid 

ulcers  after  extiiliatinn  of  the  >lnnirli-  i  lielieve.  with  ntlie.' nli-ervcrs.  tn 
he  uueninmnn.  On  the  ntlier  hand,  tiradnal  dceiieiiin;:  nt'  the  idceralinn 
i-  prnltahlv  U(  t  at  all  nire.  mi  that  nicer-  iiay  ncca-iniially  tiive  riM>  to 
perfnr.itinii  at  a  time  when  e(im|iletiiin  nf  the  |iriice—  nf  cieatri/atiiiii 
nii^rlit  he  exiiectcd.  In  the  majnrity  nf  caM-.  Iinwever.  ]iert(iratinu  dues 
lint  result  friilil  -Itch  M'cnlidary  exten-inu  of  the  ulcer  in  (le|illl.  Iiul  frniii 
the  cirenm-tance  that  the  iutlllratinii  frnm  theniitM't  extends  dnwu  In. 
even  iuvnlve-.  the  M^rn-a.  and  that,  after  exfnliatinii  i>^  the  -Iniiiih,  such 
a  thin,  unresistiiiir  ineinhnine  i-  left  that  it  i-  imt  ahle  tn  w  itli-taud  the 
lire— ure  nf  the  iiite-linal  enntcul>.  Theiv  i-  aecnr(linj:ly  a  ^r'""!  ana- 
tnmie  lia-i-  fnr  the  mn-t  fiT.|nent  nccnrreuce  'A'  i)crfnrati\e  peritnniti- 
al  a  time  whcli  exfnlialinii  nf  the  -Imiuhs  take-  iilaee.  while  the  -ccnudary 


I'M'lliilJxlY. 


97 


nl..Tition  ,n.„ti,„„..l  ,.xplain>  in  pan    ,|„.  o.vunv,.,.,.  .,C  p.rf;,,,.,!,,,,  nl  a 
iniicli  later  p.  I'iod  ,,f  tlic  .|i-ra-i' 

In  .■;,..   in  u|,i,.l,  ,|,,,tl,  lia-  .v-ul„.,l  f,,,,,,  iM„.-tinal   heniorrlia...    ,1„. 

""'""""-'  '-  - '"""■^  r„n»ront..l  u  ith  thr  i,i,,m  .lidinilt  an.l  ll,,.  -i-upl.-t 

>;'I'"..mI   proM,.,,,-   M,|,.  I,VH,1,..      Tlu.  .^..,.-.iv,.,   npi.llv   i;.,.!   I.,.' - 

.•Na,ir.s  M,av  tal<,.  pla.v  vitl,,.,-  tV.„„  lar^r,,  intestinal  v,-m.|;  „p,,„.,l  i„  ,|„. 
l-'-'"v~,  „1  ,.x(„l,ati.,n.  an.l  wl,,,..  -,nn,p.  are  ivadilv  .|...nMn.tn.U..  .„• 
MKHMv  fr,,n,  .-apillarv  v,-m.1s,  >,.  ,|,a,  even  on  p.,>,-n,.,r,en.  exanuna.i..n  i, 
;;;■'>     -  ''"'"-it   ,.,  <le,n„n>,rate  ,|,e  .,n,ve  of  the  n,a>Mv,.   lH.n,on-|,a..v 

II.-   he,,,,,n,a^,.   ,Von,    lar.e   ve...l>   an erve,l    espeeiallv  whe„   du" 

-ea  le,l  ,n,lun,„.,l  patehe,   are  exfoliate,!  a>  a  ul,ol •  in  la,-.,.  n,a„e. 

""■  Y  -   "'^'"^   ''■"•'■   ''■'""   '-'Will^'n.-  ..r  iVon n,en,u.  tninute 

Ve^M.|.    ,.  n„,    nnviv  eneonntere,!    in  the  earlier  stap.  of  „e..,-osis  hef-iv 

'•;'"" ,^':';l'7''-       l'"l'— l-i.vu„.,aneesa(e.-,orn.anv, 

-  |.l.-st  an.  o     ,1„        ,n.hs  are  i;,und  to  he  .pon,v,  .Vial.le.  irre,nlaH 
v'll-:s  >Ntln-e,l   M„h   hl,«„|.  a„.l    hiaeki.h  re.1  or  ,larl<  in  ..olor.      The-e 

'■;'"■'  ""•,  '"'''f '  ""■  '■••■•1"""^  -...nrrenee  of  eopions   intestinal    hen,or- 
rhap.  n,  the  earl,-  staj:e>  of  tvphoi.l  ,;.ver  ,„,;.,,,  „,..  ..,,.^„  .,,.  ^,,„  ^,,,.,,,_^, 


('i<'atri/ation  of  the  tvphoid  nh 


••i'-  <'<'(npies  a>  hmir  a  time,  and  often 


■'l'-^er,in,e.  than   the  preeedin^  .tap.  of  intestinal  altenmon.      That 

I'    U-t   tnne  (or  heahn.  ,s  a   n.atter  of  ...nrse.      X.,  do.l.t,  n  .der  the 

;;''•'-•<;■•'..-,.    phv.ieal   dehilit,.    the    p.„.ess  ,,f  h.di;':/^ 

......alK-  protra..,..  even   in  the   pre.en f  le.  pn.f.nnd   lih.e.^ti. 

'  :  "":  ':""-"■•>•  ""■  '"'"'"-"  •'-•■•i' .V  ...rlier  writers  as  atonie  nh.  • 

ation  1.  ni  part  to  he  inehuh.h 

.VnereieatHxation   has  taken   plaee  the  artivted  ar..s  are  .till   s.,,,,,- 

'I    I-  .1  matti'r  ot  eiiiMve    tli.it    »l,      i  i     •  i 

'<|iMs(    ttiat   the   lymphoid    strnetiircs  at  tli..  sit,.<  ,.r 

;:::::  r;."™''; '"'■■-i '•„,. ,,.„„;::;:;': 

■   .v  ::,■;::; "  -it '■"",-': "'' "- "- ™"' •"■■■■■ 

,|,„„,  .,  '    '  ' '"'"" '"■■«"'«>•■  •■l«'"«l ,  »u.n„.  wi,l, 


I 


'JH 


TYl'lIoll)   FEVER. 


vMiiMtiipii-  witli  -iirMi'd  til  tlic  iiiiiiilxr,  A/.v,  dtptli,  iind  »li>Iril)iiti>iii  of  tlio 
1y|)liiii(l  n  I-  in  llic  dilVcrciit  |)(>rtiiiM-  el'  tlic  iiitotiiio.  'I"<i  \\  liat  extent 
indi\  idiiiil  ...iidition-,  or  llie  -everily  or  iriildriess  ol'  tlie  iiit'eetion  o|)(  r- 
ale,  eiiiniot  readily  lie  -tated,  as  no  explanation  iia-  as  yet  heeii  tortli- 
eoniinir  tor  liie  tact  tiiat  the  inteii-ity  of  tlie  inte-tinal  le~ions  varies  nuieli 
dniin;:  ditlerent  epideniie-.  Aire  and  sex  appear  eleariy  to  delennine 
<lit1'erenee:-.  In  eliildlen  tile  extent  of  tlie  niednllary  swelliiiL',  l)otli  of 
Tever'-  ])alclies  and  of  tlie  -olitary  follicles,  is  on  the  whole  not  -o  jrccat 
as  in  adults.  The  »lonj.diinir  aUo  is  irenenilly  not  so  marked  a>  in  the 
lattei.  and  tlii-  <ireiini-tanee  explains  the  greater-  rarity  of  intestinal 
heinorrha^(~  ami  pirt'oiiitive  peritonitis  in  ehildhoiid.  ( 'ndoiihtcKlly.  also, 
involnlion  of  the  mediillaiy  swellinj^  hy  ah-orption  is  more  eonspieiiolis 
in  ehildren. 

With  repud  to  the  nniiihc  r  of  iiililtrateil  I'eyer's  patehe>  in  the  indi- 
vidual e;ise,  s<inu'  intestines  are  nliserved  in  which  nut  iiini-e  than  .'1  to  5 
nltoL'cther  are  atlcctcil.  In  coiitrasl  with  thtve  cases  are  others  in  which 
scarcely  a  sinide  |)alch  in  liie  lower  Iwti-thinis  of  the  ilemii  escapts;  in 
whi<'h  the  neiLdih'irhoiMl  of  the  ih-ocecal  valve  is  alnie>t  Cdiitinilotisly  intil- 
trateil  aii<l  is  iheichv  cniiverteil  into  one  lartre  ulcerative  surface.  >"ot  rarely 
the  veriiiiforni  appendix,  with  its  follictilar  apparatus,  is  iiicatly  involved  in 
the  nioriiid  procos,  and  it  may  occasionally  h"  the  seat  of  perforation.  I 
have  observed  as  iiianv  as  ;!l)  (iiseascd  patches  in  a  sinirle  hody,  aial  I  know 
that  other  w  riters  have  spoken  of  a  still  lar;ier  iiumher.  A  nioderate  inmiher 
of  intestinal  uh'crs  is  far  more  commoii,  however,  thsni  a  very  larjre  nimiher. 
In  a  stndv  of  •">U4  autopsies  that  I  made  in  llamhurL''  from  the  tiid  of  l.sx")  to 
IM.'ST  with  relation  to  the  mmiher  of  ulcers,  in  "JlW  cases  the  specilic  intes- 
tinal lesions  wen  discrete  and  in  L^reater  or  less  iiiimher.  With  reference 
to  th'j  localization  of  the  ulcers,  the  notes  of  577  autopsies  at  the  Ilamhurf; 
and  Leipsic  hos))itals  are  availahle.  There  was  involved  :  the  cecum  in  iAQ 
cases,  X.H.;i!(  per  cent.;  the  cecum  i  often  toL'etlur  with  the  vermiform  appeii- 
<lix)  in  247  cases,  42.X1  per  cent.  ;  tlu'  colon  in  \XA  ea.ses,  -il.X!*  per  cent.  ; 
the  jeiuniim  in  41  cases,  7.1<»  per  cent.  ;  the  rectum  in  I'-'  cases.  2.0X  |iercent. 

.lust  as  variations  occur  in  the  nnmher  and  the  intensity  of  the  intestinal 
ulcers  in  dilferent  localities  and  epidemii's.  .so  are  variations  in  localization 
to  Ik-  idiscrveil  also.  It  is  inten^tiiii:.  for  instance,  that  IloH'mann,  in  the 
epidemic  at  Hasle.  ohserved  involvement  of  the  larfre  intestine  in  4tt.o  per 
cent,  of  cases,  ( iriessiiiL'er  at  Zurich  in  40  per  cent.,  while  in  Tiihinfren  ihi.s 
localization  was  ohserved  in  24  ])er  cent.  The  most  common  comhination 
in  the  seat  of  the  intestinal  lesion  is  apparently  the  ileum,  the  ileocecal  valve, 
and  the  cecum  ;  with  this  is  freipiently  a.s.sociated  involvement  of  the  first 
portion  of  the  colon.  Less  common  than  this  .-omhination  is  involvement 
of  the  ileum  alone,  or  of  this  and  the  lower  half  of  the  jejuiunn  ;  and  still 
less  common  is  invoivement  of  the  ce<'um  and  the  colon  alone,  or  of  the 
lowermost  jHirtion  of  the  larL'e  intestine  alone;  while  exclusive  involvement 
of  the  desceiidini:  coli>n  down  into  the  rectum  is  jiroliahly  least  comnion. 
In  the  up|)erm<ist  |)orti'iiis  of  the  ieiunum,  and  especially  in  the  dno(lenum. 
I  have,  totrether  with  most  ohservers,  never  found  any  spe<illc  ulciTation. 
It  should,  however,  he  lueutioned  that  llamernyk  ohserveil  such  a  condition. 
In  the  same  number  of  r>77  autopsies  I  found  the  frecpiency  of  intestinal 


J'.trnoi.ot.y, 


!»!> 


porf,.ratini.  an.  oon«-.-ufivo  porilMnitis  t.,  I„.  l.',  ,„.r  ,.,.„t.  TIu-^h-  fi.Mir,-  ..rc 
almuM  „l,.„l,..al  «,.l>  those  ohtain...!  I.y  .Mur.i„.su„  tn„„  a  .olkr.i.:,,  .,t' -i.!," 
.•m.n,,H...  n„„  van,,,,..  J..„d.>li  a„-l  Fr..,,,.].  l„..|,i,al.s  .lan^lv,  l.i.M  ,.er  ....,„. 
Ih.  .tanM,rs„.  .M„,v|„.<,„,.  ,..  ..,11  as  ,„y  own,  an.  OM„,.ilV,|  Cro,,!  a  lo,  !: 
M-,M...  of  v..ars  a„,l  a,v  .l,..n.|,>  tre.  lro„,  a,ri,lw.,H  .1,,..  ,,,  ,1„.  rl.ara.t.T  o? 
ii>,i,v„„al  .iHclernKs.  llo«  „val  variations  n,ay  o.vur  in  in.livi.Jual  ,.,,i,|,.,„. 
M-s  ,s  shown  h.v  ,,,.  „l,s..rya.,onsol'  lloliina,,,,  at  I5asl,.,  who  lound  ,H.rtoratio„ 

>-  -"  "'  -•"  """'I'-"— >^,  l-r  .vnt.      Th..  ,..at  of  ,ho  ,„.rfo,-a!ion  of    1," 

-u..    ,.o,-n.s|„„„!s  w,th    n.^..rdto„s   fW-.,„..„,.y  in   jron,.,-al  wi.h   tliat  of  ,h,' 
lo.al,/.al,o„  o(   the   nleers.      Oi   1)4   perforations   that  I  l,ave  stn.lie,!   in    this 

;•; ;■'■"""•  ""■':'■  ""■^.  "'VoIve<l:   the   „|,|,er   portion  of  the  iienn,   i„  :,  eavs  • 

tlu.    lower   portion   of    the   ih',,,,,    i„   :;;i  ;    ,!,,   „ei^^i,l,o,-hoo,|   of   ,he   ijeoee.ai 
\:'."'  "1  -  :  !.;i   ve,-n,ito,-,n  appendix  in   I  ;   the  .•oh.n  in   11  ;  ,he  re,-lun,  in  ']. 

Mavin-  ron.i.len..!  the  -pe..ifi,.  alterations   i„  il,e  n„i..o„s  „...„,l,ra.„. 
""■  '"M.lition  of  those  poftio,,,  „f  tl,..  Jatv  an.i  tl„.  Mnail    i„t,..ti„e  tlett 

";:"  '""  '"^■"'^'■''  '"  ""■  !"•'«■'-<—(•  infiltfation  , |,...,-alio„  n,av  „ow  I.e 

'"'""^ ■    '  I'""  ''■'-  l"'i'>f  tl"';inato,ni,-,,l,>ervatiu„>aiv  not  -o"  sv-ten, 

-Ur  an.|  extensive  a>  wo,,!,!  l,e  .leMt-al.le  (ron,  ,l,e  ,.!i„i.,,!  ,,„i„t  „f  view 
<"Me,-ally.  reh.tvnee.  are  f,,,,,,!  „„!y  ,„  ,!„,  ,,,,,,„,„,  „,.  „.„  „„„,,,,; 
"''■M.l.ran..  „,  the  inntn-liate  vi,.i„i,v-  ..f  ,h,  I,,,,,,;,,,,  i„,i,„,„- ,„  ^„„, 
MNyra,,,.,.  an,!  esp.-eially  those  alterations  ar,.  n„.„ti„n..,!  that  are  n.ost 
'Ntin,ately  tvlate.!  to  tl,ose  pr,„.esses.  As.  i.oweve,-,  ,!„.  ••  |„t„.ti„,l 
sy.npt.m,."    in   ,,,se.  of  typhoi,!    fLvr-that    is.    .liaiTl,,.,     n„.t, 


I'te. — mi<|i)lll>tei!lv    ,1,1    II, ,t 


Illation  to  the  iiiterisi 


at   aiiv  sta 


ire  ,it    th,.   ,||, 


at  lea-t   III 


int,'-tinal    iiiiieoiis 
turti 


ty  am!  extent  of  tli,.  -peeifi. 


iTieteorisiu, 
ase   >taii,l    in   direct 


|)art,  expli,'al>l,.   from   tl 


le-io||s,  tl 


lev  iillist 


liieiiiln-ane.       l),.iil)tl< 


ler    liivestiir;iti,.ii    that    ext 


!<■   ,',>ii<litioii  of  the  ivniaiiuler  of  tli. 
it    won!,!    he    f,„in,i    ii|)oi 


III    the   tiivt  W( 


eiiMve  catarrhal    alterat 


t'Ks.  exert  a  , 


Still 
liiit  als 


let 


eriiimiiiir  iiiHiujice, 


Mils,    partieiilarlv 


aiiotlwr  (iiiest 


loil    ol 


l)trii,!e 


itself, 


'  troni  the  practu'al  staii,lp,,i,it.  ii;inie!v.  ( 


iKif  alone   from  the  tl 


leoretie, 


1-.  th,'    speeitic    iiifeelions    ,\\ 


e\i-t  also  ill  th.'  al 


■ase    ill,],!,.,.,!    l(v  the   1 


III  typhoid  (;.ver — tl 


lat 


)M.|i,-e  of'  s 


l"U-|,'  anatoDiist.  win.  fr,,m  tl 
po<t-mort,.m  examinati 


I»'eitic  intestinal  1 
div  ol 


If    liaeilhls    ,.f    F,l),Ttll 


esuius 


Kven  tile  |)atli( 


it 


111  the  nei.r;itiv( 
-lijrlit    iile,.rs    ii 


K'  nirully  ol,|,.ctiv,.  standiMiiiif  of  the  results 
iniirht  I.e  disp,.>e,I  t« 


may  hesit.ite.  with  a  kn,.wled. 


>  answer  fins  (iiiesti. 


11)11 


II   -^iieh   small   iiiiml),T 


■am,'  wav 


tliat   diphth. 


:e  of 
1 


eases  presentiiijr  such 


lav,'  Leeii  nienti,.iied.       In  tt 


iiH'inl.rane,  and  aeiit. 


ria    may  I.e   imatt,.|id,',|    with   the   f 


tloii,  so   th,.   fl.lh',., 
nith  extr 


xaiithemata  witli,,iit  cliaract<'rist 


iliir  ;i|.paratiis  ,,f  tlu'  iiitestii 


le 
orm.it ion    ,.f 


i<"  eiitaiieoiis  enii)- 


I  ver. 


.\ 


I'liie  rarity, 
most  ev,'i' 


le    mav  certainlv, 


lie  iiiv,.lved  in  minimal   <]• 


tli,.ii}f|i 


iii^^'tion,  in  which,  aft 


>   cxperiem-ed  el 


iiiieian  will  r. 


•  ■irrec   III  ease<  of  typhoid 


(■all  eases  in   this 


er  most  careful 


(■"iisKJei-ation  of  all  of  tl 


le  circiini- 


100 


rvrunih  I  i:\i:i:. 


>t;mrr-,  t\|)lini(l  t'tvcr  liMil  liiTii  ili:iL:iiii-(il,  lull  ii|Min  |MP-t-mnrt('m  fxnm- 
iiiali'iii  <'iil\  llir  uiMrral  m|>|":ii';iii<'i-  "t'  a  |irci|nunil  inliiiidii-  (li-rax' 
williiiul  -|)icilic  liM-Mli/Mlimi  wcrr  tnmnl.  I 'iirnrliiiialrl\ ,  -iiili  ca-c- 
wcrc  toriiicrK  net  i  xainiinil  liai'tcrinlni^icallv .  I'n"'!  -till  Mtiii-  In 
1)1-  waiiliiii;'  llial  lv|iliiii(|  ti\ii-  can  uiciir  uilli  im  It^inii  wliatrscr 
ill  llic  ■ra-lni-iiit('~tinal  trail  iln.aii:  any  -la;:r  d'  lln'  ili-ra-c  Tliis 
|Mi— iliililN.  liM\\(\(r.  iiiii-I  alway-  In'  Ihtiic  in  iniml,  ami  -iMTal 
aulliciilic  c'a-(-  lia\f  ixcii  i(|Miri(il  wlnrc  lr-ion>  (MnM  imt  In'  I'umikI 
at    anl(i|>-y. 

liir  changes  in  the  mesenteric  glands  >ian(l  in  inn-t  imi- 

nialc  rclali'iii  to  tiup-c  cf  tlic'  intc-linc.  'riicy  ari'  a-  (•(in.-taiiliy  iniai'iircl 
a-  llir  i\  in|iiialic  -irnclnrc-  nf  tiii'  iiil(-tinr,  and  like  tlicrii  cNliiiiil  llic 
cliaractrr-  >>i'  inciliillary  intiltratinii.  in  ;:rni'ral  ai-o  llic  locaii/atinii  of 
tlic  |ir(icc->  ill  tlic  iriaii'i-  ciirrc-|Minil~  with  that  cii^loniary  for  tiic  iiito- 
tiiial  h^ioii,  so  tiiat  the  ciaiids  in  tiic  lower  paitt  of  the  ileiiin.  the  eeciini, 
iiiid  the  adjaeciit  parts  of  the  colon  are,  on  the  whole,  involved  nio-t  iic- 
(liieiillv  and  in  lireatc-t  de;:ree  ;  while  iho-e  in  ihe  n|i|>eniiii--t  [lart  of  , 
the  small  iiite-tine  and  the  lowcrino-t  |iart  of  the  lart:<'  inte-tiiie  more 
frccnieiillv  remain  wholly  free  or  are  hiit  slijihtly  iiivolvid.  This  (orre- 
siioiidence  will  naturally  not  lie  i'oiind  eoiiiiilete  if  larjre  nnmliers  of 
ea~e^  are  studied,  ruder  e\ee|iti<iiial  eireiimstances  jiroloiiiidly  involved 
iHirtions  of  inte-tiiie  may  exliiliit  sliu;ht  Ld:iiidiilar  involvement,  while,  on 
the  other  hand,  a  sliLditly  dcvelojied  intc-linal  le-ion  i-  sometimes  asso- 
ciated with  disproiiortioiiate  Ldaiidiilar  hypi  rplasia. 

The  enlar-remeiit  of  the  ^dan<ls  alino-t  always  exten<ls  fiir  lieyond 
the  narrow  zone  of  those  most  clearly  related  to  the  intestine,  (ieiier- 
allv,  thoM'  of  the  stomach  and  the  ]iortal  ti-nre,  as  well  as  the  retroiieri- 
toiieal  and  the  lironehial  jrlMiids,  are  involved.  The  ehaii^'-es  may  exieiid 
even  still  further  to  the  lymiih-fxlands  in  tin'  vii'inity  of  the  iiKHlth,  the 
larvnx,  and  the  deeiier  strnetiires  of  the  tiiiiee-,  as  well  as  to  those  of 
the  iie<k  and  llie  iiiiriiinal  ylaiids. 

The  eidarjrcnieiit  of  the  ineseiiterie  trl:iii<l>  does  not  liejrin  niiieh  later 
than  the  infiltration  of  the  lympliatie  struetnres  of  the  intotiiie.  The 
^rlands  heeome  prominent  as  early  as  the  e.nnmeiieemint  oi'  the  second 
week,  and  attain  their  jrreatest  size  at  the  hei-rht  of  the  di-ease.  They 
are  then  <rPiuTallv  fnun  the  size  of  a  ])ea  to  that  of  a  walnut,  or  even  as 
lar<re  as  an  ejr<:,  tensely  clastic,  fmni  ^'niyi-h  red  to  Mnisli  red  in  color. 
jrlohular.  and  with  a  smooth  or  s<iinewliat  iio(hdar  surface.  On  section 
the  proieetiiiir  glandular  structure  is  more  markedly  re(hleiieii  in  the 
cortical  than  in  the  medullary  portions,  the  latter  at  time-  preseiitiliL^  a 
irravi-h  re<l,  and    in    the  center  even   a   yellowish  red,  appearance.      On 


;,^r^  A^  -  =*-  *r, 


.►v--w  V-^_V-**  *-<*  »^.»  iweij.  .  . 


r.\riiiti.(i(.  y 


101 


li-i"M.      'I'lic  -Willi 


iL'  ;^ro„.   ,,rujr,.,.,Mv,.|v  l,.,<s.  tli..  ,.„|,,r  l.,.,..,,,,,-  ,,,|,,, 


thr.,M,l,   al,-,,-,,n„n,  ,,  turn  ,„  ,l,..i,-   nnnnal  h/,..      Thi-  mhhI,.  of  inv.'lM- 
; '-•  ""  ''""'"•  ""•   """■'■  '■■-">"■'-'   M.i.l    iMvvMl.nt    ,„„..      N,„    ,,,„K 

'"'"'■;'■'■• "  "  I"' ''■''  ''>• ''  I'-''-  -'»■  -ti,.ni„.  i„  ,1,..  .i„„|,  ■.,-i;i: 

--y     „.   ,,,,-.„,    i„     null   M„.U.  ,„.   „.„„i,,„  „,,,,   .  ,  ^,^„.  „,^    ^^^_.^^   ^^^. 

'"■-'■""'•    ''•;-■"<■'"■■'  'M..,  „.,v  ,i...„  .„„,„,. .„,,„i.„;,,i,,„,,, 

'"7  '■"""""".'>■  '^"-"     'i"-  ...'  th..  .lan.l  ,„•  ..v,.„   ,1...  ,.„,i,.„  ,.|„i,, 

;'!"';''""r '"'""'."-  ^""' '"-'"'-"  ^vm  ,i„.„  i,..  „„„.,,  ,„„,,.  .,;„;„,„ 

::,;'':":""^ t"'-"":" ^"'""^'"•- •-■•  i>.'H;..,ti..L.„a 

I''""'' ^'■"  ^''■ll.■rMl  |>..nt,.iiiti-  i.iav  r.-iilt 

^iver  and  Biliary  Passages.- 1,  i,  ,.,.n.aH<al,l..  that  tl,..  l,...t 

;;:'""; '!''-'i--'.<i->,,,,„i,, ...,...„..  w,,;,...;: ,  , 

.'■"-.-    .n    „s  >tn,..,„,v,    .lis,.,.nnl.|..   ......    ,„a,.n.,.opi  allv       Tl,,... 

:; :  ;:'r:;'7.'''';'''''':' '••• ipaiN-, ..,...:„.,.'.,.,.;....,. 

'  P '"  "^ 'V'"'"' -''•-■■yi..^  .ii>.in..,M.ss  at  ,iin;.p..„t  .t..,.. 

.na,.;:::,: '';;;:■'  rr^'rrr ;'';■'■"•■""•■" -•'■,-.....,.- 

.ii..a..  I :„::,    '  ""^^ "  "'""''  '^-i'^  i--  -"•  ti..... ..r  ti.e 


<iiM'a>c   III   ^riiirra 


I'l  iIk'  riiid.ll,.  and   toward   the  vu,\  of  tl„  i         .      , 


y    Crom    til,,    snrti.,-,.,   ,„,„•   a,.|„.ars 


r::r'' ;;::::";':;'• r; -"■-"■v-™s; 

'li-"l-iatio„    with     .,     V  11         1       ■  '"'   ''"'    '■^"■"f    """•'<"<' 

••'■  '-li :r:  •  :,,:■';;;:  ;;;; '-  •;^'-->  ''.-.■■■  pn....atio,. 


102 


TV  I'll'   i>  I  i:\i:i!. 


—   i  •-■■»T»  . 


MiilM-c(.|iic    i\ai]iiii:ilii.ii    dl'    tl,,'     li--iir    nf    tlic     li\ir    di-ddM-.    in 

<'"'''''-|' llllic      «illl      lllc      IV-llll~      ,,l'     liiMilii-i  Mjpic      lAMIIlill.'ltJoll      .lIlllM-l 

liiii'\ci'|ilii.ii;ill\    in  llir  fc  liiili-  -l;ii:r,  nidic  oi-  !,—  .nlvanccd  allriMl ion-  in 

the    liv<r-iTl|..      '111,-.     ,i|,|i,:ii-   at    tii,i    ajliurni -   an<l    tiitl\,  ^rarnilar 

:niil  Iniliiil  :  an<l  llirv  tlan  iMr.iMic  -w.illcn  aii<l  lillnl  |iriii;rr— i\ civ  with 
\:\v^i-  an<l  -mall  -laMnli-  ami  tal-ilii.|.-.  ami  linalU  l.ivak  n|>  inio 
tlrl;;IU-.  'I'lic  ili^rnc  lali\r  |i|-nci—  ;^cli(i'allv  l)c;.rin-  al  llic  liirililiriv 
<(t  tile  li\  ci-lnlinlc,  ami  ranlv  atlain>  llir  -arnc  dc^iiv  al  llif  (inl.irMii 
ill    il-  tiutlicr    |.iM-iV".       Al   lir-1    llir   -niiiilar   anrl    mil, id    cdU  can  lie 

clcarrd  iip  l.y  addili I'  acrtic   arid  ;    I'lil    -nl.-.i|iirMll\  .  il'   |)i(,Mr,.— iv ,. 

fat-intillratioii  taki-  llic  |.laic  nt'  alliiiniimni-  ^'I'Miiiilal  ion.  tlii-will  lie 
|io--iMc  III  hilt  -li-ht  il(-ivc.  if  at  all.  In  ca-.-  of  .-|Mviall\  -rvciv 
iiii-ct  and   Ion-  dniali.Mi    tlir  par.  inliMn  itoii-  dii;iiicTalioii  ami  the  di-in- 

l"',i:i':ili I    iIk'    liMi-li-Mic   attain    -o   marked  a  dcL'ttc    that    llic  or;:aii 

i)ccoim>  diiiiiiii-li(Kl  in  -i/,  ,  tlahhv ,  and  pale  ^ff.i\  i-h-\  i  ll(.\\  in  .oloi.  and 
i.-  tlin-  -ii;;;;i-ti\c  of  llii'  condition  oh-.ivol  in  acute  \cllo\\  atro|.li\  of 
the  liver. 

\\a;:llef'  doelihed  a>  a  -|ieeitii'  feature  of  t\|ilioid  fever  the  |ir(>encc 
of  >inall,  ^icnerally  interaeilioiH,  ;;ra\  i>li-«  liite  mKliile-  in  the  li\cr- 
ti>.-iie,  which  he  dcMiilied  a-  accniniilat ion-  of  l\iii|ihoid  cell-,  ,ind 
con-idcred  :iiialoM,,n-  to  the  lynijihoid  hy |ier|ila-:a  <'i'  the  inle-tinal 
iollicle-  and  the  -imilarly  eon-titnted  iiodiili-  of  the  |peritonenin. 
Iloti'inanri  oli-ei\ed  llie-e  liirrnation-  in  .".S  o|'  •_'.",(!  ca-i-,  lint  he 
lielieved  them  to  lie  actually  >till  more  eomnion.  Later  examiiiatinns, 
however,  lia\c  not  >howii  them  to  he  [leciiliar  to  ly|ihoid  fe\  er.  a-  thcv 
have  heeii  oh-erved  in  other  ilileetioii-  di-ea-e-  al-o.  IJeed.'  tVolil  a 
>tiidy  ot'  tlie-e  -o-ealled  lyiii|tlioiil  nodule-,  concluded  that  the\  are  not 
c(im|)o-ed  of  lyin|ihoid  cell-,  lint    that   in  the  earlier  -ta^c-  the  ahiindanf 

tiiielii  |ire-eiit  ari-e   in    le— er    |iart  from    the  di-iiite^rnili 'I'  mi<lci    of 

the  liver-cell-,  and  in  :;i-eater  p.-irt  arc  tho-e  of  |Hp|viiior|ihoniielear  Icii- 
koeytc'-  which  have  wandere<l  into  the  neer<itie  area.  He  tlioiii;ht  the 
neci-o-i-  was  jiroliaMy  not  due  to  the  immediate  pre-ence  of  the  tv  jihoid- 

haeillii-.  lint  |irol.alily  iliie  to  the  acti t' ;i  cireiilatin^-  toxin.      Mallorv' 

think-  there  are  two  varietie-  o|'  the  local  Ic-ioii- :  one  con-i-t-  in  the 
tiirmation  of  |ihairocytic  idl-  in  the  Iv  m|>li  — pace-  and  ve— el-  aroinid 
till'  portal  vi-.-el-i,  and  i-  due  to  the  action  of  the  toxin  ;  tin-  oiIk  r  is 
due  to  the  <ilistrii-lion  of  livcr-c-ipillarie-  hv  pha::-ocvtic  cell-,  derived 
ehiefly  hy  eiiiholi-m  throiiMh  the  portal  cir<Milat ion  of  cells  oi-ii.diiatinjr 
from   the   elidotlieliiim    o|'  tile    hlood-v  c— el-   of  the  inte-tine  and  splewi. 

'  An-/,,  il.   Ilrdk..    IWIU. 


./../,„.  ll.,,,ku,.-<  Jl...y,.   Uq,.. 


/,"C.    Clt. 


I 


r\Tllnl.(,(;y 


1();{ 


■'•"■'-"  "'''  '"'-PI-"--  i-''i  --  aM-  ,„  - ,„  „„„„,,..  ,,|^.,i;;„ 

l">".-M  iIm.  ..v,.l,„i.|-l,.,.i||u,  an.l  ,|„...  ana.  T|,.,  ,.|,,n„,.,,.  .,,• 
Il"'    I.Nr   r.,nv-|.,„Ml~  «i,|,  ,l„.,A„„Hv.   .Iian...,    i„    ,|„.    |,,,n.,„l,x  ,..a  ..f 

''"'   ''''•'■•    ^""'   ''"-    -■'■I'""",    in   -■ nHli-,i„r,i,,„    |,,„„    ,|,ai    in   .,tl„r 

•"•"I..  M,t,,„„„-  .1,.,,-..,  i,  .,.M...allv  Ii.|„  i„  ..„|„,  „„|  |i,„|,i,,  1,^ 
-|"..li.'  .^laMU  ,-  |„,w,...„  KMO  a.Ml  luhi.  ,.  ,.,„„,.an..|  will,  IV,,,,, 
'"-''    "'     '"•"'    '""''■'•    "i'li":iO     ,..,n,iiti,„„    ||!,„i,a..l,.|).        MiMl,     |,..s 

";"''"";^-   ^"    '^    ""■    '"'•••    ''"•    "-'^ ■    i"    'M'iMo    nv.r,    i,    i,    vi.Ml 

ami    (lark. 

<;'■<•"  iMNHM  lias  .v-vntly  l„.,.„  a.,,-a.t,.,|    „.  ,|,.,  MUatonn-  alterations 
".  Ili.'  lar.,.  I„liarv  ,,a.,:,^,.,.       |    1,..,,,^^  an,!    ,v..n  .li|,l„|,..n,.   uy,n-,^.,^ 

'"    "",    "^'"    "'■    ^^'I'-l'l-M-'    -,.|    ,1,..    L,,....    Lilian    ,.a>.ap.,    with 

-.-M.laiv  ,l,.Mn,,.,i,,n  an,|  al,.......-  in  , I,,,  li.,  ,,,,.,.,,,, ;;,,.,iv,,  ,,,,H,,,„i,is, 

"'    '"■'■; ''     '"■•"    ■''■-""•''    -^    -■'■' unvn,.,.-    ,An.lnl.    I..ni„ 

;''■';";■'■•      ■'"•''<.    l;<.l.itan,kv,   an,|    ,„|„.,.,       AH..,- <  .ill-rt    an.l  ( lin.l..  ' 

';■■"'  '"■~'  ''" ~"-^"'^'  'M'l".i.l-I.a,illi  iMti„.;:all-l,la.M,r,(|,iari-.|,„w..,l 

"':"    ""•—•;•   I— ^    in    rl„.   Lilian-  ,.a-s,...,  w,.,v  in   p„..,„|  ,,,., 

I-M.,,.k,,,,|,,..      ,.,,,,,,,,.,,,,,,,,.,  ,,,,,^. ,,,,..  ,,^„,„,,,  ,;„.„.,„, 

'l-^nll-MnM,.,-.       II,.  wa.   al.l,.   .,.  ,l,.n,on-„.,„.   ,|„.   l,a,.i|li    in" -..  ,.f  •'•> 
^'Nt..,.H,.>.     Nnnlar„l,..,vati„n~  u,,-..  rna,|,.  I,v  l;ir.l,-Hir<,.|,(;.!,|.' w|,„   i„ 

;'"''■'"""'  "'"'  ''''i-i ■"■''"''-  <'-t    .1-  ^all-l.la.M.T  ,,rol.al.lv  ..n^ti- 

""'■-="•""" '•""'  m,i,.,i-tani  > •,.,•  f,,,-  ivinllvtiun 

'''  -''li'-''  '-ii-'t  -..--..,,(•, I,..  ,,|,.,,,,n,„   ,,,,„..„,.,„,,,  ,^,_„^^^ 

y-    '""^'^"^  "'   ""■   -'"■'• li"^-   l-I-ti.'  pa.vn,.|,vn,a,  al f  ,1;. 

'"■'■'''^'•■'^''•'"■■^'^'■^'''■'^l''''-''--Mn,l..,-.,,|,,.,. .,|i,i,.„.  ,,.„ 

-P      ..   .n,     ,an.tv,|,|i,i.      F,,,-  a    n,..,...  .|..,i| |....,,!ti,.n   .:,•    I  i; 

;;': ''''''^ '■'■''•'•'■'';r .'->■'-'•'■-''■'■•  •! h-.-m  ,.a,t  „,' ,i.is w,.,.,. ,. 

•■-      .n-.wn   ,.|,n„.al    ..,,„,„. -   an.l    ,1,,.,.  „,•„„,.,,.,,,..,, .,^  ^^l 

Changes   in   the  pancreas  a,v  n„.n,i„n,.|  l.v  f,..  writ..,.,  .,„ 

'"■'"'•'•"■"■'■  '"    ""'"-' ■'■-•^--.nt.  an.i    .,,,..,vn.ia  of  tl.  .:;:   ill 

y.ri,ri,„.-i,.i,,,.,ti,.  .I,,,,/.  jAuir.'  iM.  ii.,  s.  (;n4. 

/''■  Mi.rh.,  iininis,,.  (idttirifrc!!,   17i;l'. 


)■,.. 


;.">'■ 


M^- 


m 


inl 


TV  I'll' >i  II  1 1  \i:i: 


il,.  I,...li,-  ..r  t!i.r-,  A,  mI  ..!'  f.  |i!i.  i.!  u  \,  1.     Il.irniMnii'  w:i<  f!ir  fir-t  to 

i|i\ir|r  iiMilllloli  |riit  iiiiLilU  I'l  llii'  iMihTci-,  Mini  lie  (il(-(l\  I'd  ('li:iiii;c  ~ 
-iiiilLir  til  lliM-c  ill  ilii'  -;ili\ji\  L^laiiil-  n  iiiiiiiiir  willi  i  nii-iili  r;ilili' 
refill. iiil\  .  Ill  iIh  lii-l  |i(  ili'<l  ..I'  l\|i|Miii|  I, Ml'  IJii-  i^Liih!  i-  'iriici'iijiv 
•  •111  ii'i;c'il,  li:iril.  L'i':i\  i-li  i''l.  ^H'l  i'\in  ni'ii'i'  (l(r|il\  H'iI  in  i'ipIoj-.  <  >ii 
liiicrM-i'djiii'    I'MiiiiiiiitiMii    llirri'will    III'  iMiiiid    i|il:it,iti<>ii    ami    nv  ii  lilliiiL'^ 

111'    till'     -iii;iili  I'     :nii|     -lii:illi'-t     \i'--rl-,    uilli     -ii'i.,,-     iiitilti';ili I'    tin' 

•.iiljiirciil.  -lill-iiitai'l  ]iaiiiii  li\  iiiii.  Ill  iIh'  l:itir  -Ia;:i--  llir  |iaiirrca-, 
wliiili  al  (ii-t  \\a-  riiiai'L'i  d.  Imiihih'-  di-ruli  hi  d  and  |nt-i'iil-- a  L'l'avi-li- 
\i'lli.«  111'  I'Mii  L:r:i\  i-li-lii''i\\  II  a|i|H'araiii  r.  Tnuard  llir  riid  nl'  llii' 
allai  k  ill!'  |iaiirri'as  au':iiii  iM'ri.iiic^  diiiiiiii-liiHl  in  -i/i'.  and  iipmi  i'iiin|>li'tr 
rri'iiMTV  aiijiiii'i''  il-  iiMi'inal  ciiii-i-li  ini'  ami  nilm.  In  the  srrund  -la^rc 
the  inriia-r  in  tiir  -i/r  o|'  tlir  l'ImihI  a|i]M'ar'-  In  lir  dr|irlidint  n|Hin 
iiilari^i'iiiriil.  iiiiilli|iliralion,  and  arli\r  ili\  i-imi  ot  tl'r  rrll-,  ami  llic 
di-i'ciliu'atiiili    ii|MPii    allpiliniiinil  — t'altv    di'^iiin-alii'ii. 

HEART  AND  VASCULAR  SYSTEM. 

Lillli'  i-  UniixMi  riiiininiiiLr  tlir  aiiatuinir  I'liiidili'pn  nl'  tlir  invoranliniii 
in  llir  i  iiial  ami  llii'  tir-l  llliiili'  -la'.^c  mi  aciuniil  of  llic  larily  dl'dralli 
at  tiii-  |H  I'iiiii.  (  iriH'ialK  ,  llir  >i/r.  riin-i-lrni'\,  and  riiioi' 111' tile  niMirar- 
diimi  ari'  dc-ri'ilird  a-  nmnial,  altlinii'^li.  cxiii  in  rarlv  -ta;;!'-,  im-rca-rd 
fVialiilitv.  tlaliliiiu'--,  dilatalion,  (-|Hiialiy  "t'  tlir  i-ij.dil  liall'  nl'  tlii'  lic:irt, 
and  di-ciilnniii'in  111' till  lirai't-iniiM'lf  lin\r  "ftcn  Imi'Ii  niriiiiuiiiil.  Tlic-c 
cnndilidii-  aliii">l  fnii-tantlv  unnr  in  'lir  Iniulit  ot'  llic  di-ra-e  and  tlic 
snii~ri|nrnl  ci'iirx'  of  tlir  rrlirilc  rtaiir.  Tlii-  \va-  kmiwii  alrrady  to 
carlii'i'  iili-i'r\  (I-.  I-ainmr -'  >|ii'ak-  ol'  '•  Mit'trniiii;- "  ol'  the  licaft.  with 
violet  iir  lirii\Mii-li-vi'llii\\  di-rnlnratiiin.  Siili-i'(|iii'nllv.  Luni-,  Stuko, 
and  ilokitaii-kv  iravr  di'-i'ri|ilinii-  ut'  llir  iiiacrii-cii|iir  cliai!^''!'-  in  tin' 
licart-iiiii-cli'  at  llie  Iniirlit  nl'  tlie  attack  ut'  typliuid  t\\v\-  that  at 
till'  prr-iiit  dav  ai'r  -till  ciin-idiTcd  iiiudrl-.  Nalni'iilK,  tlir-c  uIimtn  rr- 
wcri'  nnalilc  In  advaiiri'  inatrriallv  tlw  rliniral  riiin|)i'rlnii-iiin  "t  thi'-c 
mndilinii-.  It  i-  onlv  within  iTcriit  liiiii'-  that  a  rlrai  iii-iulit  iiitu 
tlir  natiirr  "('  tlir  t'liiii-tiiiiial  di-tiirliain'i--  '4'  tlii'  Inart  in  «'!i.«c.-  nt" 
t\'|)hiiid  t'i'M  r  ha-  limi  nliiaiiii'd  a^  tin'  rr-nlt  ut'  a  lai'L''''  iiiiinlicr  iif 
valiialih'  -tiidic-  ut'  llii'  hi-tuluuif  rhatiL'i'-  in  tlif  iiiyurardiiiin.  At 
tirst,  nr.diT  thi'  lradri'-hi|)  u|'  N'irrhuw,"  a  nniiiliir  ut'  |iari'nrliyiiialun< 
cliiiiiircs    and    cun-iTiitivc    rr;:i'ni'rati\  r    |)ruri--i'-    wi'iv    c-talili-lird    liy 

'  f.ur.  cit..  (1.    I'.il  ,/  s,;i. 

'  Trait,'  ill-  rn„K.-„l/.it.,,ii  hii'./i.it.-.  -, iid  .'.litio?,.  I'-'jr,. 

■'Sop  thi'  tarinni-;  jirtifl''  ujion   ]i;ir"'iu'ltyiii;it.'U-  iii;i:iiiitn:iti"n  in  Vn-rhnv' -<  Ari'lih\ 
\M    iv. 


—    — 


=,-       J.--        «       J-       *J-        --- 


/•  I  I  ll'iln,,  ) 


105 


^§ 


i 


"■'"'"'■''  ^••"'^"■'    ^\^'l'l'--.    Il.'lln. .•  ll.u.,n,'a,H|„f|„.r<,  fowl.;,  I, 

"■'-   -"'-'l".M.K    a,l,l,.,l    a    I .I,.,|„.„,    „„.r-,„i.,l    M,.l,„„M,:„„n    ,„■„,- 

.■---,    (,.-!    .,Hl„al..l    l,N     ll;n,.,M.    a,„!    ,v,.,.,„K    i.ui.mmIU   .,h,,n,,,|    |,s 
liiillllirri.'^.' 

•^ "-  ''"   ['••"■-■ii.liyiMMi.,,,-  -ih,  r..ti..ns,<...n«i.lii  iii.M,  ~1„.mM  Im  .Nvm 

'-|"-l:llK     t.,  ;,ll,u,„i,„,i,|    -nUMllali.m.         I...-  ,.,, „,.,„„,.   ,  -|.....i;.||v    ,„",,„„ 

"■"■'•''  ""''  '"I"--  ir>li.t,.,N.  ,li-...„.,,  ;.,,  ,;,,  in~t.u,.-,,,li|,|„l„.,.,.  ,|;,„„. 
I'.r,,,  ta,u.  a„.|  i„  i-„la,..,l  ,„..-  |^alin,•,  uaxv  ,|,..,.,„.nu  ,..„  I,av,.  I,.,,, 
•■'-'■'^■■■I.  Ina.Mili,,,,.  .I,..,v  ,-  ivinarUaU,.  -nlar;;,.,,,,  nt  ..f  ,|,..  ,H,..|..i 
'"  '!"■  '"'"I  "'  il-nv.ili..u  ,,r  ,li-i..Mli..ii  ali.K.-,  .■n,„,a,itK  al  lr,.|  i„ 
|"lnll>,  "ill,  almn.lanr  ,|,.|„Mti„M  „f  ,,i.„M.„t  in  .l„ir  vi.ini.v  ,Ko,„- 
1-^r,.       II'".'.,,..!..-.!!,,.,,  ,|„,„„.,,,,.„,^..„.,,,,i,,„^,  ^,„.,  ,^,.  ^.^^;.^^^l^^^^^^^^ 

^""'  ^'  l"'"l,ar,.|,anu..  in  tl„.  lo,,,,  „f  ,„„>„.,•,.„-  ,,an-v,.,-..  ,..ar.-„.v.. 
-.n  ,„.    ...M,.,„a„v    ,|;,.„anl.i-„|,i,.|,    1,„„.,,,„,    ,  „„    |;„,.Ui„.|,,„.,„ 

/.mLt,  an.l    ,v,.,.n,K   aU,    I: l,,..  a,-  ,|., ,.|    , „,,,..,,., .j 

|iii«liii't-.  '" 

■'•I-  l'^"'n;l.vmarnu.  al,..nHi,,n.  Iku.  Im.,.m  i;,nnJ  in  l,.arN  ,nv-,.nliM.. 
' •' ■"l"-l^|i"l'•-l-'^■■.--ll:.-in,l ,l,a,  .n„„,l,..ir..x„.n.:i 

;'';'";"' ';; ';'■ '•-•— -1 ,. ,„,„  i„,„. ,.,,,,„,;„„.,, 

"'    ''"■    "'.--^"■''"""    'I'MM    i„    ,i„.    ,ni,l,ll,.    lav,.,-.  u|,i,.l,  |,ow..v,.,- 

^;':  T^""" -"'-'''-'"'-'i .-.i„„.MK 1,;.,.^,  x,„ ,,„,  • 

";;■';  ""■'"'■'"'■''^'"^" l-n,v.  an.l  , .li„i,.aUv,„p, , 

'■"""'•  '^' ■■'^'•:^'^'- "'•''■•'-■■"■■'"■  iM..TMi,ial,;,v,„.a,.,li,i..„,,i,., 


:;:::;^:;;;''f '■':':''■' •-■  i.i^--i-...n,„..i...  ,„  .1.11,1,.,.. 

■"'"""    ■"-    ' "    '''-■'• 1     I'.v     |-n„,.|,    „,,„,,,,,.    ,„,,,,„      ^,.„.,.,, 

:;; ;p""  -;[  '■'■' ■'••  ■ ' <i''^i...a„.  „,.,i;,.,.a,i„:;.,    :. 

'■•'-'-   I"    "lii.-li   -11,1,1,,,,    ,|,..„| ,    ...        ,,'  ■..       .       """"  '" 


i:.l    X 


' "    '''■^'" "'••■-I    '••'   '-'il.-.l-'.      II,.  .|....n-|„..   ,|„. 

""■'^ --li.^ui,,,,,   |.„v,„.l,w„:a„„-   inll,u,„na,i.,n  in    I  V.y,  „„■■.. ,,,/,;,., 


ggw,,,  ir^^^v'  ;^-x^mmm& 


^^^^;rdi:yt 


^t 


TYI'IKill)    ll.VI.Il. 


ail'cctioii  ;i-  MM  inflMiiiiiiMtniv  li\  |i(rpl;i>i;i  c.t'  the  I'dliiliir  elements  of 
llie  iiitliii.i  '<(  tin-  -mallii- .iil<  lit-,  wliirli  :i-  a  it -nil  -iitVi  r  eiiii-itltnilile 
tliifkeiiin^-  nt'  tliiir  wall-  aiitl  iiarinw  Iiil;  tif  tlieii'  liiiiieii.  Ivomlierjr 
lia-  Iteeii  aMf  111  vfiil's  llit-f  iili-ti'vatiiiii-  imlv  in  i-njatet!  iiislanfe^, 
anil  tlitreti'Te  witli  ;;iK'!  rea-nii  f\|ire>-es  (iinilit  a-  tti  their  tVei|iient\ 
Miitl  i^fiiti'al  .-it;nitifaiiit'.  S.i  lar  a-  i-  kntiwn,  the  inliamniatdrv  iinx't-s 
lAIiiitl-  in  -nth  a  ua\  that  litiih  the  riulil  anil  llie  lel'l  -itie-  nl'  the 
heai't  are  iiiMiKtil,  the  latter  uenerallv  in  niTiiirr  ile<;i'ee  anil  I'rei- 
efiihlv  at  the  a|ie\  ami  the  ha-e.  Ktmiliert:  wi-  alile  tti  ilenmn- 
strate  that  the  in\ neavtlili-  t'iti|iientlv  iiii;:iiiatetl  iVmii  similar  intlani- 
niatiir\  |n'iiee— e-  tii'  the  (\i-eeral|  ]ieiieanlinni  ami  the  emlneariliiini. 
As  elinieal  i  \|ierieme  al-ti  -liii\\>,  the  iiitei--lilial  niyinai'iliti>  aiijiear-  in 
a  iiiaiiir''s  ut' ea-t- tn  nmli  I'^rn  etunpleie  iiixnlntinn,  witlmnt  lea\  int:'  i'lnie- 
tiitnal  til'  aiialtiiiiie  ili-tiiilianee-  in  the  inyneariliiini.  In  rare  iiislaiiee- 
(vipii  I^evilen.  iidinliert;  |  |>ei-nianent  tihrniil  ehani;e  can  jimlialily  he 
(leiiiensti-aleil.  Whether  al  i-ees- i  it'  the  hear'  may  lie  a  result  has  nut 
lieell    ileimili-traleil. 

In  idiilraili-timtioii  tVnin  ntlier  iiiteetiims  lii-ea-e-,  endocarditis, 
esiieeiallv  that  iii\i>l\  in^  the  valves  ami  teriniiialin';  in  \al\iilar  li-i(in> 
iif   the    liearl.   i-    eMlvniely    rare.        \'ei;etati\e    iir    llleentive    emhieaiilili- 

al-11  '<u\y  e\ee|itiiiiiall\  enmc-  inidcr  (ilp-eiAatiuii  (( irie— iiij^er,  Lieher- 
nieisler,  IJunehllt ).  Several  ease-  have  lieell  reporteil  ill  whieil  the 
t\  pllniil-liaeilllis  ill  |ilire  ellltlire  \\a-  i-iilated  tViim  the  atVeeteil  valve. 
I'rdjiiliK  the  le-ioii  i-  n-iially  ilne  to  -eeomlary  iiit'eetiun  with  the 
|i\i.i;ellie  etieei.  KuinlielV  tlil-  ealleil  atlelllioll  In  foeal,  ecllerally  niliral, 
eiiilneai'iiiti-  liesuml  the  liiiiil-  nl'  the  valve-,  ami  ileimiiistnilile  only  on 
niierci-enpie  exaiiiJialioii.  It  appear-  rarely  to  aeipiire  eoii-iileralile 
ex.eiit  ill  ea-e-  of  ivphoid  ti  xcr.  ami  to  aeijiiire  elinieal  -i):nitieaiiee  only 
miller  -])ei'ial  eomlitioll-.'  With  a  certain  decree  ot'  pret'el'eliee  it 
extends  deejilv  hv  way  ot'  the  xc— el-  or  the  illleiStiee-  lietweell  the 
iiiii-ele-.  tliii-  i^iviiii!-  ri-e  toa  direct  t  iii-itioii  iiiiM  iiiyoearditi-.  Aeeord- 
iiii:  to  IioinlierL;.  iiioiv  or  le--  e\ten-i\e  ri iiind-eell  iiililt mit ion.  the  >oiiii  r 
for  which  coii-i-t-  ill  a  di  ii-e  network  of  -mall  vein-  and  eapillarie-  in 
till-  -iiiiatioii.  i-  pre-ent  more  freipieiitly  in  the  depth  ot  the  \  i-eeral 
laver  of  the  pericardium,  at  the  innction  lictwccii  it  ami  the  -iiperti- 
eial  laver-  of  the  iii\  ocardiiiiii.  Tlii-  inllamniatory  proce—  al-o  extends 
iireli'ialilv  deepK    into  the  mvocardinm  and  rarely  towanl  the  -nrtace  ot 

the  pericardium.      (Iro—  form-  of  pericarditis,  with  lihii -  de|)o-il- 

or  f'lid  inllanimatory  ctTii-ioii.  apfweeialile  niaero-co|)i(ally  and  i,ri\  inir 
ri-e   to   clinical    matiiti-tation-.   i-.  TieeordiiiLdy.    (jtiite   exceptional.      In 

'  Sri'  til'-  ;i|i|.rM|iriii|i>  -■■1  lii'iriii  ihr  ilini.  :il  |.urt. 


PATIIOLOOY. 

i-.lMt.-d  in^tancs.  it  is  trii,.,  I  |,av..  Cm,,.!  fihriimus  .|,.,,.,si,s  upun  tl... 
l'«n.ani„„n,  ,„  a.->u..iati„M  wi,|,  .•,.,M,.ii..atiM^r  cT.,u|,nus  i..u...tn..nia,  ainl 
iM  a  tru  ,M>tan,r^  |.unil,..,t  |„.ri,aniili>  as  a  |.a.t  inaniflstation  .,f  ,■„„,- 
|ili<aliiiir    -r|)~i~. 

Tlu.  ,l,aii-,s  JM  thr   la.-,.  v,.>s,.|s,  Mltl..,,.-!.    ivs, >il,I,.  (I,,.;,  ,„„„|„., 

"t  n..t  ii.i,„rmn.,n  .liuicMl  inanif-.^iations.  |,av..  as  vt  n.,t  h.m  tiior- 
niiirlily  st(Mli..l.  Th,.  veins  aiv  in.,iv  rrv.|.u.ntly  aiUvf.l  tl.an  tiir  art,- 
n<-.  Tv|,l„,i,l  ,,!,i,.|,i,i,  a|.|M.ars  m  l».  tlic  iiM.al  ••auM'  fur  i.hi,.,.iuaH'i 
^'11'^'    'l"l<ns   .jurinjr   .•o„val,.s,.,.|Kr    Inmi    typlioi.l    ii.v,,-,  \vi,ik.  a  "iMriai 

va>„.,y  „f  ai-tcTitis   is   ,„ al.ly  r,.s,,„n>ii.l,.  C,,-  sp„Mtan.„us  jr...,-,,,,,.  „f 

tl.-  ..xfvnuti,-.  whirl,,  i;.rt„Mat,.|y,  is  ra.v.  Tl.,.  aMat,.,„ic  ah..n,ti„„s 
ti.at  tak..  |,!a,.,.  aiv  .-....-i,!,.,.,,!  i„  ,|,,,:,ii  ii.  a  lat,.,-  >,.,.,i,„..  t.M.,.,lu,.  wi,|, 
tl...  .•l...,.al  ...a.,iti.stati.msj  |„  ,|,..  s.n.,.  s.vti,,.,  will  I,,.  (;.„„,l  a  .•..„.- 
l.l.t,.  .l,.-,.,.,|,t.,.„  „f  the  Stat,,  ofth,.  i,l,„Hl  in  «...e.s  ol"  ty,.h„i,I  lever. 

THE  SPLEEN. 
In    its   lu.|.avi„r    th,.    .,,],.,.„    i>   ,.„„,,,a,,,I,I,.    essi.ntiallv    t..    P-.v^r". 

I-t-he~   a„.i    ,h,.   i;,liie!,s   „f  ,1...    int,.stiMe    = the    nu..,.nt..rie  ,lan,K 

-.!«•  the...  ,t  „  ain.o.t  always  swollen  at  tl„.  ...,„,n„.n,.,.„....,t  an,l  at  the 
l."|.'l.t  of  th,.  ,li,..a>,..  In  any  ..v...„,  al.,...,...  of  ..,.la.-K..,n,.nt  of  the 
>|.le,..,  at  tl...  ,,e,.io,l  i„  v.M.tl.f.,1  a.,,1  ol,|..,.  in.livi.lnals  „n,h.r  the  am>  of 
.|.-ty-.,ve  yea.s  is  n.o^t  ,.x..,.,,tional.  A,.a,t  tn,...  a  (i.w  .-a.  .s  in,.xpli,.a- 
'I"  '"  tins  ,.onn,.,.„o„.  it  a,.,„.a,-s  to  l„.  wa,.tinj,  onlv  aft,.r  ant,r..h.nt 
■iMa-e  ot  ,h,.  ..,.,„.  ^i,i„j,  ,,;,,,  j„  ,„„,i.|,„„,,,„  ^,„,,  ,^,_.^.^,^,^^j  ,hi..k.,„in. 


'"  .t~  ..a,M,l,.  or  ,in„  hyperplasia  of  its  sfo.na  ( Ilofr.nan,.,.  an.l  th,.,-,.|,v 
|»n..a,..„,ly  .|,.,n,yin^  it>  ,li.t,.,.Mhility.^  ,n  ,.|.le,.lv  ,„„,.,„.  .,,,i^ 
;;;-|'l.->f    th..   .ph.n  at  tin,,..    p....v,.n,s    the  oee,.,.,.en,.;.of  t.,n...f,..ti,>n. 


■ri  I  ,    ,  '         ■ .  ..I  HIM-,- oi    ii.n.eiai.tloi 

lu.  ..n!a,^..n.....t.,t  the  .pi,.,.,  i.  ,,.o.t  n,a,-l<..,l  at  the  l.,.i.htof  the  i;.|.,-i,e 

p.;r.',  winl,.  at  the  ,.o„,n„.n,...,„..nt  of  thi.  sta<:..  a„.I  in  in.livi.lnals  ,lvin. 
;      the   sta,..   o,    .lefl.rves,.,.n....    i,.    voh.n.,.    i.    not   n,a.-k..llv   in...... a...l: 

•  -l-^.n,..nt  o,   the  sple,.n    i"  typhoi,!   f;.v,.r  i.  h.   ...nen.l   not  v,.,.v 

-.1-^l.ie.      \\  h,.n   the  sw..|Ii,,,  i-  a,  its  .,.,.a,...,.  the  ..r^.„   ,,.av  1. 

:;;■";•    ""■"•*•    '';"-'>-•       a    „-..at..r  .l,.,. f  enla,.,..n„.nt  is 

-;-.,.  V   .„...,  an,    ,v..n   ..nla.^.......n,   to   th.i....  ,1,..  .n,al   is  .li>p... 

;'■''''''''■''•■';•''''''•'',-••'-'• "-t an.l  a  half  tin,...  or  tlvi..e 

^n^  .1...  n„.a.„,.,.n,...,ts  of  the  spl,..„   i,,    ns   f,eal   ......  of  nphoi.l 


'  ^''|.  ill.-  iliiii.iil  ifi'tii,,!. 

';i':'.M,'\h:.'::::;r,;;:  x:zi  t;;:"',  7"-t"' •  -^"--f-i«^.e,„entof 

..11  Aiiuly^,,  ,,t  till.  Iiid.vidiiiil  Syiii|it.iiiis. 


I^^^'^ffifl 


108 


TYfiKiih  ii:vi:r. 


I)|  UA1  ION  <>i     iiii; 


U,rk. 


10 

11 

l:; 
11 

ir, 


•JH 

81 


Total 


I'- 
ll         1." 

11 

48 


1 
51 


1 

1 

1 

1 
1 

43  21 


14 


Tile  caiix'  lit' the  tiihir^ciiu'iit  nf  tlic  --ijlct'ii  i>  ti>  lie  atti'iliiitiHl  to  two 

main  tnctor: (li<ttiitioii  willi   lilood  and  li\  |>crpla>ia  of  tlic  tissue.      It' 

o|i|)ortiiiiitv  !)('  atf'onlcd  to  examine  tlie  spleen  from  the  middle  of  tlie 
tir-t  to  the  middle  of  the  -eeond  week,  the  or<_''an  a]i])ears  smootii  and 
tense,  npon  -(Htion  dark  red  in  color,  extremely  hloodx ,  with  an  indellnite 
ontlint .  Toward  the  end  of  the  second  and  in  die  third  week  the 
oriran,  \\iiie!i  has  hecome  still  laruvr.  is  softer,  at  times  dark  l)rowni~h 
re<l,  even  brownish  i)la<k  in  color,  and.  while  previonsly  the  kniti'-hlade 
drawn  oxer  the  ent  -nrface  removed  litlle,  it  now  readily  takes  >vith  it 
in  considendile  amonnt  the  mnshy.  ditHncnt  splenic  pnlp.  ^\'ith  the 
advent  of  dcferx'e-ceni'c  the  sjilecii  underiioes  relatively  r.ipid  diminu- 
tion ill  size.  The  previously  di-teiideil  eajisnle  hecomes  relaxed  and 
wrinkleil,  and  the  hxperemia  >uli-ides,  xvhili'  the  hyperplasia,  especially 
that  of  the  -tronia,  |)er~i-ts.  The-e  chanp's  result  in  a  lijihter  color, 
the  tran-verse  -ection  preseiitiiiL^  a  \  I'llowi-h-red  a|)|)earaiice,  at  times 
vell<iwi-li-Iirown  t'rom  the  proeni'c  of  piLi'inent,  while  the  outline  ot'  the 
stroma  liecome-  aiiain  more  di-tiiict  and  the  knife  removes  ^carcely  any- 
tliinix  iVom  the  cut  uri'ace.  The  entire  oriraii  now  ac(|iiires  a  pi'cnliar 
touiiii  cou-i-tcnce. 

AiuoiiL^  otlii^r  altei-ation-  in  the  -ple:'n.  infarcts,  which  are  rare  and 
are  dependent  upon  throiiiho-i-  or  emlioli-m  of  the  splenic  arteries,  and 
ali-ci-.~e~,  xvhich  are  still  I'arer,  may  lie  mentioned.  Not  all  of  the  con- 
dition- that  haxc  hccn  ilc-irilnil  liy  <-,iiliir  oliMrveis  a-  ah-cesses  are 
ti)  he  coii-idcred  a>  -uch,      I)oul)tless,  old  di>colored  and  softened  infarcts 


'^m 


m^t§^>-2  Wf^mmt^^-^^ 


*l»7=i 


m 


^] 


'.'^Kb^ii 


k7«S31 


I'ATlloi.ixiY. 


Mf) 


liaw  l,c..M  in.'lii(I.K|  hi  xhU  .l..Mri,,ii„„  Tli,  tn,..  al.xvss.s  ,.f  tlir  >|,l,.,.n 
■aU'  mi>|h.:,iim  |,Mi-t  t.MVMilt  from  infiuviiun  (.l.nii.r,  II..tl:nann,  I.,m.Im). 
Olh.r-  Miv  M  pan  iiuiiiCc^tation  uf  -..ii.n.l  Mj.-i-..  H,,,!,  indnvt.  and 
al.-.r-(-  Miay  ni|.Iiiiv  i„t.>  tlic  alMlominal  cavils  ami  -iv..  n>,.(,,  uci.Tal, 
111  more  tavdiiil)!,'  ca-,-  ciiviiiiiMTil.cl.  pcrituiiiii-.  S,iiu'  ca.-o  of  ••  -|,„ii- 
taiirun^-  n,,,t;iivof  i|,r  ,.x....-hv,.1.v  .IU.-ihI.-I  >,,1,,.|i,  f,ll,.,l  with  l,loo,i. 
at  the  height  ,,f  an  r\r,.,.,liM-l,v  -cvciv  attack  of  tvph.pi,!  fcvcr  aiv  al~o 
'•'■''•'■'■'■''  '"  i"  'li''  litcraliMV  (l,ncl,l.   I,cii,l,t).      AhlioMu-h    Mich   cax-  aiv 

aiuono.  ,|„.   ran.  ,.v,-c|,tinn~.   aii.l    cad,    i„-taiicc  i-  t,,  I,.,  ac.vptcd   with 

irrcat    rc-,.rvati they  certainly  cannot    l,c  entirely    iirnore,!   in  view  of 

the  extreme   teii-iori,    -,,ftn(--,  an.l   att..imation   of  the  ca|Milc,    Mich   as 

(Hcin-  in   that   or^an   in  severe  and   i.rotracted  ca-cs. 

The  liner  altcnitions  in  the -plccn,  which  hive  l)een  alrea.lv  ,]cMail„^I 

hy  immeio,,,  olwervr-.  ,.~pe,ially    liillroth  '  and   Bircl.-Hirsehfcld,-' arc 

nlat..|,  a^  i-  known  at  the  prcent  day.  in,,M    intiinatciv  to  tlic  inva^ion 

"''  'I l•L^ln    i.y  the  lyphoid-haeilli. 

which    diiriiiir    the    felirile    sta^^e    of  0^-. 

the     di-ca-c     are     (|iiite     con-taiitlv 

|>iv-eiit   in   tlii-  orj:an  in   ahiiiidanc^ 

and  in  piriiliar  arraiiL^emeiit.      'I'hev 

are  ,|i-tril)Mted  throii-hont  the  orjraii         ^\~u*^\! 

ill   the  tlirin   of  innnnieralde  irrc-rn- 

larly  arraiiired   jr, |„,  ;„   whicli   the 

liacilli    lie  so   cl,„e    too-cthcr  that    in 

-tamed  -cetions  th,y  ajipcar  a>  dark, 
<il>ai|ne   spots,    at    the    |)cripliery   of 

which     individual     hacilli     may    \ie 

rcco^-iii/alilc  (Fijr.   7). 

Ill  other  respects   the   liist.ilojric 
alterations    are    in    ^ren.  nd    scsircciv         Fi.i.  7.-si.,.tinn  ,.f  tt„.  si.i.e,,.  .h,      ,., 
•liff'Tcnt    from    those    of    the    acute  '•"•""i'^ -f  typhni,i.b,„iiii. 

1-  —larly    with    ..verdistenti„n   of  the  cavernous   veins  of 't L  pulp 

■'-iwuh     ,i..thera.Ivai.ee   in   tlu.   tnorhid   p,.ce.s,    tnost   active   hJpei; 
•'';;;'^'  ;'  ""■  ■"■l'""--  -I--.ts  of  the  splec,  and  of  the  stmma,  together 


V '  / 


\ 


with   til 

ol*  Mtl 
ill 


'■  ^'PI'''''n.n..e  of   th.wc   larp.  cells  (phairocvto,  eontainiiiir   ,,.1 

""" '■•■"^'•''•-    "'"'•''    ■•'■'•""fly    I'^'V"    M...,i.in.l    such    ..reat    tlu'-oretic 

''""'"' •      ''"'"■  -ij-'"i*i<'=i"'"  of  inrtaniuiatorv-cha.ifresin   the  Miidler 


I 


V-r,'hnu-'s  .\rr},)v.   H.I.   vNiii. 


11(1 


TYi'iinii)  ri:\i:n. 


&ii:r-: 


:irl(|-ics   111'  the   -|ilc<'n,    to    wliicli    l'"rcii('li    iiivotiLiitoi's  ojh  cially    liavc 
ilirt'ctrd  att<'riti(iii  (Sirtilcvj,  \\\\>  not  as   vet  Ikcii  .-iilliciciitiv  otabli.-lied. 

ALTERATIONS  IN  THE  URINARY  ORGANS. 
A|>art  iVoiii  the  rari'  ra-t>  in  which  (hath  take-  ]ilacr  in  th.'  carlv 
stairc"  'it'  ty|ihoiil  t'r\cr,  tlic  kiihicv-  i^iinrallv  cxhiitit  nmri'  or  h-s 
niarkcfl  alterations  a|>|ii((ialih'  to  the  naked  e\ c,  which  arc  coni|iaralih' 
to  those  in  otiier  [larcnchyniatous  or^raiis,  es|iccialls-  the  li\(T.  At  the 
Ix'iiiiniin;.''  or  the  middle  ot  the  second  week  tiie  kidne\>  ai'e  usnaliv  still 
of  noianal  -i/e  or  Iml  -iii;htl\  enlarLieiJ,  n^iialh  L:reall\  rcddeneil  n|Min 
their  cMernal  a~|iiet,  njion  -eeijon  niarke<lly  li\  |iei-cniie,  so  that  the 
niedidlary  -iriicliiri'  ntien  i^  dai'k  i)lni-!i  YtA  in  color,  the  cortex  some- 
what liti'hter,  troni  I'ed  to  i;ravisli  red.  \\  iti;  the  proj^ress  of  the  disea-e 
the  oi'Lran  t.enerall\  nnderLjdis  t'ni'tiier  eniart;(inent.  It  lieeomes  lirnier, 
its  color  lii^liler,  and  the  ca|i~nle  rcniovahlc  with  dillicnli..  'Ilie  cortex 
now  a|i|iears  eidart;cd,  pale  ^ravi^li  re<l,  otten  with  a  \<'llowi>li  tint, 
while  the  |i\rainiiU  tor  a  time  retain  their  dark-red  color,  with  the 
exception  of  the  papilla',  w  lii<'li  soon  aci|nire  ;i  \'ellowi>h  ap|icarance. 
After  a  lon^  and  >evcre  attack  of'  fe\-er,  e^peeiallv  in  protraetid  ease>, 
the  kidnexs  »nlisei|nentl\'  lie<-ome  ^maller.  flalihier.  and  often  liiihtcr  in 
cokir,  in  the  same  wav  as  has  heen  mentioned  with  rei.''ard  to  the  liver. 
The  diminntion  in  >i/e  ^^cncralK  takes  jilace  at  the  expense  of  the  cortex, 
which  now  a|)pcars  smaller,  an<i  |)ale  grayish  yellow  in  color,  wliile  the 
inednllarv  snhstancc  al-o  l'rei|nentl\   liecoTnes  xmiewhat  paler. 

The  alterations  dc^ei'ihcd  ai'c  the  macro~co|iic  expre— ion  of  the 
hciiinnini:'  pronri's^ixc  parenchvmatons  dcirencration,  c\-entiiall\'  attain- 
ing'' a  hi^h  jjfraile.  Micro-i'opicalK  thi-  is  nianill'sted  liv  allpnminoiis- 
fatty  tnrliiditv  of  tlii'  epithelial  cells  of  the  nriniferou-.  tnlmles,  which 
soon  inideriro  >  iireon^  -wcllinir,  lieconu'  tilled  with  -mailer  and  larj^cr 
t!it-i:lol)nle-.  finalK  di-intcLTate,  and  thn-.  to^ritlier  with  iiinnmerahlc 
h\alini'  and  Liramilar  tnlie-ca-l».  oftiii  oicliidi'  the  nrinitirons  tuhnles  for 
a  con-i'leraMe  distance,  'i'lie  cells  are  then  pre-ent  constantly  also  in 
the  'loii'ly  tlnid  that  can  at  this  timi'  lie  expressed  from  the  apii'cs  of  the 
papilla'.  Till'  parei.chymatoM-  dcL''' ■Herat ion  almo-I  always  hei^dns,  as 
can  111'  di-tintrni-hi'i|  with  the  nakeil  eye.  in  the  cortical  strnctnre.  and 
onl\-  later,  and  often  not  in  e(|nal  d'nfre''.  1-  the  mednllary  strnelnii'  also 
in\  'lived. 

The   alteration-   ik-crilicd    ha\c   lucn    n Lrni/''il    tiir   a    eonsideralili' 

time,  at  least  maci'n-copicallv,  as  part  manilt-tation-  in  cases  of  tyjihoiil 
fever  of'  miiderate  and   of  scvtTe  course.      (irciror\  '   and    iiaycr-have 

I    i:.l,„l,     M..I    .}..„,■..    IKII.  ^  M,l.,.l\fs,l,'»    ,:,,,.■<.    1S40. 


r-T    :--.--     -fl  Til — TU  «i    -  -»- ^' 


l'.\rWil.i)i;Y. 


Ill 


nr.nv,!  to  !l,is  cniiditio!!  in  rui,i,rril,,n  with  ili.rij,.  MiiiiiiiiitiMnM,  .'m.j 
ll.-lliiMMii  '  :m.i  K.  \VMj.rii,T,-  ii|H..i  tli<.  I.M>i>  „t'  ,  xt.n>ivc  -t;iti-ti(>,'hav,. 
•  ii.cii-M.I  it  ill  :in  .xliMilstivf  maiiii.T.  In  v.m-  .a^rs  tlir  .liaficrc^"  n„.„- 
tioiM.I  ,],,  nut  |,r..c.v.l  Im;,.!,,!  tJii,  Miif,^  ;  l,iit,  un  i!„.  cij,,.,-  hand,  .■jini- 
.•ally  u,  ll-,l,tiiir(l  cMiililioiis  of  a.iitc  iicpliiiti-  al-.,  .„viir.  'r|„,,,  ,„,,v 
:i|i|H'ar  raHv.  in  the  mi.l.llr  .,f  tlic  >..,-.„m1.  ov.h  at  lli..  iiul  ,,t'  tlic  til-"t 
\\vv\s,  aii.l  tli.v  may  .L.tiiinatc  tli.'  i-linical  pictiiiv  to  mu-Ii  a  ilc-nv  that 
Fiviich   ..l.-,.rvci-s   ,-c|>,rially  havr  tMl  jiistili,.!  in  a|.|.lyinir  ,,,  siirh  ,,,m..s 

''"■'''-'^'"■"' plirotvpli.n,!.'      'riuanatonii,    |.i,tiiiv  ,,f  tv|,|i,,i,|  n,.,,h- 

rili>  i-   irriMnilly  that  ,.f  acute    i.ar<.n,.h_vni  il,,ii-    hrinon-hai;ir    iiitla.iniia- 
tion.  ii~iiaik  \Nith    -nlM.nlinalc    iiivoivrinnit  of  thr    iiit.T-litial    li~Mic. 
Wa-iHi'a.i,!  NMi,  K,rklini;han>,M -■  liavc  .•all...!  attention  to  a  iHcnliar 

variety  of  iiepiniti^  atteii,|,.,|   with   niiin.i niiliarv.  intei   titial,  pnfii- 

lv.it  lo,.i.«hieh  in  raiv  ea~e-,  a-  I   have  niyMJf  ol,..,-ve.|  in  one  in'>ta , 

may  eoale.-.v    into  al,Mr-es  varying  in  .i/,.  f,,„n  that    of  a   Lean  t     that 

"'  '•'  "' "■      '^'""  IJ-'Min-haiiHii  had  alna.lv  attfii,nt...l  this  alVction 

'"  '■'"'"'''  "'■"'■'■'• •'■'■•     -^t  '!"•  I'lvx'nt  .lav  th.r,.  i>  >eaivelv  anv  ,|,,nl,t 

'''^"    ''"■   '" ''""    i-    ii'M'Tally    of    M.,,tie  ori^rin.       liou,.ver.    ea~e<   of 

""''"!'''■   ='''^''<-^'-    i"    til''    Mdney.    ,ln,.    ,o    the    aeti f   ,h,.    tv,,|„,i,j- 

I'.naPii-.  may  oeenr.  a-  in  tii,- ,.a>e  ivporte.!  I,v  Flexiier."  in  wliiel,  there 
"^i-  a  .y|,ho„|  .e|,tieeinia  with  toeal  ah-ee~~e>  in  tlie  iu.ln..v,  from  «  hieh 
tile  ty|.iioi(l-l,arinn~  was  iM,iate.|  in  pure  enitiiiv. 

I"  '"le  ease  I  ha.l  th.^  op,«,rti.nily  „\-  examininjr  ,]„.  ki.l,,,.,,.  f,,,,,,  ., 
"i:iM  dead  after  m  niptoni-  .,f  pure  heiii,,ir|,,j,ini,ria.  The  or-an-  were  „f 
nofinal  sixe.dark  sepia-i.rown  in  eo|,„.,aiid  iinns„allv  hanl.'  ()„  s,,.,i„n 
tln_  .■'..•lex  nas.lirty  hrowni^h  i^ray,  the  pyia.nidal  tissi...  ,lark  l.rnwnisl, 
>■'■''.  .'Mio.t  Idaek.  The  lena!  epith,.linm.  I.oth  in  the  eorfx  an.l  in  the 
""■''Hilary  ti~~i,e.  was  in  a  Mate  of  alhiiminoii-taltv  elondir,..  an.l  ,ii,- 
iM|"^nited.  and  the  eonvoi,„...|  and  >trainh,  nrinillrons  tnUles  were 
IdI'd  wirl,  masses  of  l,rounish-r,.|,  .lisUtmij:  iiemodol.in  tnlH.-.,i.ts  an.l 
naki>. 

A^  in  th,.  liver,  Wajrn.T  l,a<  ...■.■asi,„ially  ,I,.monMral,..l  in  tl,..  ki.ln..v 
■'-  >h,.  pr.s,,„r  of  Miiall  ,.rav  Ivmphonialous  „.,dnl,.s.  wliLO,  .h.v,|.,;, 
^'l;"o.,    ..x..lnMv..lv    in    th,.   ,.or,i,.al    tisMi..   in    the   ininie.liat,.    vi.-initv  ..f 

;;"'";!'■"•"'■'-•       "'■tlmannlia~ol,..rv...l    tla.n  half  as    Ireipu-ntlv  as  in 
till'   Jivi'r.  ' 


/....•^  .-it. 


\  f^'" ■"'    """■"■■"■'■  ■'■:■  spr,.;rlln.    /'„//,„/,,,;,      |i,|     j,   .   ;,     \„f 


'   i.nr.   ,;l. 


|>"rli-    ..   I)i-iiir-lii 


tl..   I  Th 
•11  !)).■  IVirt  ..r  ti,, 


V.r/,a,„ir  ,1 


<■(   I'nih. 


"/  /.V,-/..    \> 


:i"i.   V..1,   ii 


-./.  (irs,-//..,-/,.  ;.    n„r:/„ 


■//.    1871. 


m^u 


1 1 -J  7  1  riiniii  I  i:\i:i:. 

Iniiinl-  lit"  tiic  ki(liii\-  iiri' iiliMiMil  i:ml\,  1  Intl'iii.iiiii  liaviiij,'  iMunil 
tlii'iii    III   liiiK-   ill   "JMI  :mlii|)-i<'>. 

'I'lir  ;ill<  nilicill-  111  till-  irinaiuiirr   uf  llir    iiriii:ii-y   IIMi-l    MI'i'    ixlniiirly 

tmniiii II  :i^  ( i|);nril  witli  tliii>i'  ill  llir  kiiiiiry-.       1   liavr  ill  :i  iiiiiiilur 

lit'  iii-tMiiccH  i.liMrviii  iiiiiliniKiii-  liriiicirrli:i;^i'>  nt'  ciiii^iiii-ralilc  aiiiuiiiil 
ill-  iiiiiiHTciiH  siiialiri-  ixtrava-aliuii-  of  Mnod  in  tlir  iiiiirnu-  niiiiiliraiif 
of  liic  \h\\U  o|'  llic  kidiicv,  a>  llirv  lia\r  lii'i-ii  ili-i  rilicil  liv  I.oui-  ami 
liavri-.  I'linitcnt  [iNclili-,  wiiicli  ai-o  i~  inciitioiinl  in  tlii'  iili  ratiirr.  1  have 
never  I  necdintered.  Tile  iniicoii-  nienii)raiie  of  llie  ui-et<i>  i~  rarely 
altcnd.  here   anil    lliere   -mall    1m  niorrliai:!-  are  oee  i-ionally  -inn.      'I'lie 

iirinarv    lilailder    like\\i-e  exliiiiits   more    or    lo-  e\teii>ive   Ik rrlia^i' 

into  the  niiii'ou-  niemhrane  only  in  rare  easo.  At  tiini's  tljoe  are 
associated    with    calarrhal    state-,    or  even    •■  di]ilitliei'ie  "  destruction   of 

the    mil |s    iiicinKraiic.      (Jiiile    e\ce|itioiially    the    latter    ^dves    rise   to 

]ilii.';;nioiioiis  inllaniinatioii  of  the  wall  of  the  liladder,  with  |)ertonitioii 
;ilid  jieritoiiitis. 

Tile  urine  of  ty|iiioid  |iatients  may  contain  very  larL^c  nnmliers  of 
tv]ilioid-iiacilli  without  t:i\iiiir  rise  to  syni|)toiiis  or  si^iiis  uf  an  associated 
cNstitis.      ]-'re(|iicntly,  -iieli  mine  contains  a  lari^fr  or  smaller  niimher  of 

pns-cells,  lint  it  is  not  iine nioii  for  typhoid    urines   not    so  inlecleil   to 

contain  a  few  piis-cclls.  To  the  condition  of  ty|ilioid-liacilli  in  the 
nriiic  without  associated  cystitis  the  term  ••  lii.cllluria  "  has  liecn  nivcii. 
Tiiis  occurs  in  "J'l  to  '■)'>  per  cent,  of  all  ca-es  of  lyphoid  fever.  It  is 
diltieiilt,  however,  to  dniw  a  sharp  line  lietwtcii  the  cases  of  liacillnria 
and  those  of  true  cystitis.  The  presence  oi' a  cystitis  at  auto]isy  is  a  llirc 
occurrenec.      It  is  |>rol)al(le,  as  llortoii  Sniilli'  siijiecsts,  that  a  liacillnria 

olilv  jrives  rise  to  a  cystitis  wlieii   tlier -curs   inarkinl    retention,  or   if 

the  liladder-walls  should  lie  daina^retl  in  any  way.  Vounj.'-'  has  rc|iurtc»l 
a  most  intcrestiiiir  ease  of  chronic  cystitis,  due  to  the  typlioiil-liaeilliis, 
persistinjr  seven  year-  after  the  attack  of  fever.  He  has  collected  from 
the  litei-.itnre  two  other  similar  ease-,  ha\iiij:,  however,  a  shorter 
dur-.ition. 

The  po— iliility  of  infection  of  the  hladder  irom  without  liy  intro- 
dnctioii  of  the  tvphoid-liacillus  oii  a  sound  or  a  catheter  has  reecutly 
hcen  .su^^cested  liv  a  <a-e  reported  liy  IJrowii,''  the  liladder  of  wliiih 
showcil  an  acute  iuHainmatioii.  (  ultnres  showed  only  Uacillus  tyjilio- 
sus,  and  the  onlv  apjiareiit  jiossilile  mode  of  infection  was  liy  means  ot  a 
catheter.      This  ease  is  ap|iarently  iuiii|ne. 

I     '/'//.     ri//)A..„/-/«/K,7/».v  „,„/    7',/;./...,./   /■■...  ..     Lnliil.lM,    I'.HM). 

■'  Ju/iii.t  Jlujjkiii.-!  llusp.  Hrj,..  V..1.  viii.  »  .y,'(/.  He,-ui;l,  Murcli  1(1.  I'.'CtO. 


itvAP 


■« 
¥ 


I'MllDl.t/l,  ) 


ll.J 


ALTERATIONS  IN   THE  RESPIRATORY  ORGANS. 

Thf  n,i-,il  ,;ivitv  ij.ii,  rall.v  .xliil.ii-    the   appcMiMrrr,-  ,.f  .•,it;,rrli  with 
^••"1'      -'''■'■•■ii"ii.      At     liiii,-.   (-|«cially    wlicii    ,,l,MiM:il,'    .i.i-ta.xi,    Im.s 

lakri,  ,,i;„-,.  .Iiiriii-  lit-,  su|„.,-ti,.i;i|  rr,,-iuii-  and   I,|u,hIv  -iitlii-i ,C  the 

' '-    iiiriuKranc    of    the    tiirl,inal,-    aiMJ    the    M.|,tuM.    atv   |,iVM.nt    in 

I''"'--      *''■""! '   •i"'l    'li|>lillrii.-   ,lr|M,-ii-    in    the    Malv.-   iiiv   "aiv,  and 

aiinw-t  aluay-  nnly  in  a-ociatiun  with  iilu'  proccssfs  iimu  thf  .■-oft  i.ah.tt- 
and  il ,,-iU.  ' 

I^arynx.  — I'lKiii     the    miKMUs     intinliranc     .if    the     laMnx     mild 
'■■"•'ii-lial   inaniliMalion-^   aiv  ani..n^Mh,>  nioM  fr, ■.|n,nl  or,.,im'nc..s  ;    K.>s 

'■""""""'>  ''"•>  ■">■"■"  ■'  ' -idrrahlr.l,-,,.,.  ,,f  xAcitv.     Kvcii  h.n!i..,,,| 

"''•'■'•"i""  i"  miMrr  ora,!,.,  o.vnr-  in  a  lairly  lar-r,".  |,rn,H,rti.,n  './th,- 
>v\viv  ca-.-.  (;ri,,<M,|jr,,,.  f;,|„„|  „„.i,  „|,,.,,,  i„  o,;  ,„.,-  ,,.nt.  ,,f  the  fi.tal 
«a~,.s  Tlir  n„„v  .rv.iv  t.v,,l„,i,|  ah..rati,.ns  in  the  larvnx  aiv  int,.,v-tin.. 
='■'-1  iM,,„,rtant.  K..,.,,  '  ha>  .■,.ll,.,.t,..|  an,l  ivvirw..!  2l'1  ..as,..  nUtM 
''•'""  'I'"  I'l-ratnr..  „,.  f,  iSi.S.  Th.-..  i..si.,n.s  ^.n.Tallv  an>..  fr-.n, 
>M,M.rl„.,al    ..,„-„m-,    whi.h    „,ay    ra|,i.lly    ,„.n..tfate    .l..,.|,iv    an.l    -dv,. 

'■,'"■    "".;'^""~'^''    "''•'■'■^"i with    ,„.ri,. „inti>   an.l    .l..:tn„.ti.„r  ..f 

""■  <'an,la,-...  ri„.  n.nal  s..at  ,.f  ty|,i,.,i.l  ni....rs  .>f  th..  iarvnv  is  the 
i-~t..n„r  M,t..n,al  wall  ..f  this  ..rfran,  uh..n..,.  ,h..v  n.av  ...vt.'n.l  ,.,  the 
l.-t,.r,„r  |„„.,i„n  „f  .|„.  v.,..al  l.an.ls,  p.,„.rally  i„  th..  »l,nn  „f  sn,K.|-li,.ial 

"'■"; •      ""  ""■  l"-"'i"'-  avails,  h.,w..v..r,  th..  nh...rati.,„  is  ..ft,.,,  .1,,,, 

"  "7'  ^"""'''•''  "'"'  -""  i-  -'"-'  "f  •!''•  adia....n.  pafts,  th,.  .........n^ 

"""''";;-"•;'<    <1-  arvt..n.,i.l  ..aftilaj:,.s,  an.l   th..  in^H.-r  of  th..  larvnv 
;;;l";-"v"';<al..v,...al,.„nls.      X..    .-an.ly  tl,..   ,.,..,. ...ss  ,.xt..n.Is  .^vn 

.•l-..h-,.w  .l,.v..l,,ps  ,n.,st  <V...,n,.Mt.y,  with  .M..,-,.  ur  less  ,.xt,.nsiv,.  ,„..,..>- 
>■>  ot  -h.  r,.,,.„„l  ..artilaj,,.  an.l  ,h..  ant,.n..i,l  .-artiiajres,  whi..h  .|,.s,r..vs 
""•  •".■""■■;  •l..-ou,h..nt  a  la.-.,.  ,.xt,.nt  an,l  n.av  inv,.lv..  th..  Iatt,.r  in 
-'-MS.  u,tl,  total  ,.xi;.lia,i..,..  Th..  ,.ro..,.ss  n.ay  ..v..„  ,.x,..n.l  h.t..  the 
-  -  ,.m,n.  I,.a.|,n,  ,.  ,.n.,.l.ys..n.a  an.l  i,„il,.,ti.,n  .,f  th..  n...liastinn,n 
"itl,  ,,ns  as  o....n,.,v,l  n,  ...w.-al  ..as..s  ..i„„|  l,,.  k,,,.„  . 

V't    M"";''     '<-    '•"".".on    an e,„tiv.:   l,.si.,ns    ,.f   the  ..pi.h.ttis. 

ip'^lotn-  in.livi.lnallv  .„.  in  -n „s       \,  ,;,„„, i,  ,       "j-"'    "t    t '., 

,,,,i|,„. ,  1  \.  r     .  -""'I'^-      -^t  «"'"•- ""v  '■>.t<'>'<l  down  t..  the 

;""!■  u,  an.l  ..a,,-,.  ,.xf,.l,at,on  of  sn.all  p„ii„„s  „f  i,..  |„„,,..,..      F,t,.„. 

:;7'--""'"'7"'''l—l'i.i.-nsis,.a,-..,  an.iwh..n    it  ...... n.-s   it   ,„..v 

;;v..,no.  than    half  .,f  this   .n,..tn.....      P.„.i., h-i,,  .,.,,  ,. J^ 

"■'    tliMo.l  ,.a,-.,la,..  appears  to   1„.  I.y   fh,-  th..  I,.ast  ..on„n..n. 


^:m^;ym^:,^^m^: 


£^n:A-^. 


1 1 


TYriKiii*  FEvrn. 


Witli    ii'i:iinl    tci   ilic   iiidilr  of  "liL;'!!!   "i'   tv|>li"iil    iil^iTatidii   of   tlic 

1:1I\11S  mill  it-  -(■(|lltl-  the  1:1-1  wnlil  li:i-  iml  \il  l.icli  -;iiil.  To  inii-iilcr 
lliilii  :i-  ••  ilri'llliiliil,"  III  llic  -lli'l  -ili-r  o|'  till-  Uiil'il,  ;i-  ( ililiT  u  lili  I'- 
ll ii  I,  i-  a-  litllr  iu-lilii  il  a-  llir  a--iiiii|iliiiii  llial   tlic  r T  i'\ti'ii-i\  r  li-imi- 

Mii  iliK'  |o  Inir  ili|iiillii  lia.  A  |i..rliMii  <A'  tin'  ujri  r-,  ,-|Mciali\  tlm-r  nf 
till-  |iii-li|-iiir  \\ail  I.I'  till-  lar\ii\.  iniiloiililiiliy  aii-r  I'lniii  -ii|Miliriai 
I'lo-iiiii-  ami  li  — un-  ot  lln  niiirnu-  iiiiiiiliiain  .  wliirli  tinii  ]iii'lialp|y 
iiiiira-r  ill  lA'iiil  llir"ii'_ili  -rri'iiilar\  iiit'irlimi.  Ill  aiii'liirr  jir'nii]!  ol 
,•■1-1-    ll.r   iMiilili"!!    i-    rri'laiiiU    i  li|  ii  In  Im '    iijiuii  a  |i(i-iiliai'   alVrclimi   nl 

il„.    Million-    iiiriiihiaiir    in     llir    loii'i    oi'   an    inlillralii t'    it-    1\  iii|iii- 

rollicli-.  wliirii  in  il-  naliiiv  i-  roni|iarali!i'  willi  that  nm-Ianlly  |ir(-riil 
ill  ill,  inlr-tini'  ami  otlnr  oi^^nn-.  'I'lir-r  -wnllrli  l\  iii|ili-rollii'li-  oii'iir 
i-|)riialK  at  till'  lia-r  of  i  ■  r|iiiiloll  i-.  mi  llir  |.o-tc  rior  wall  lirlwrrii  the 
ar\iiiioiil  rartilaiii-  ami  al  llir  |io-ti'rior  allarliinriit  of  llir  \oial  conl-. 
ami  llirv  apiiiar.  lifr   llir   oilier   lyiii|ilioiil    iiilillralioii-,  lo   iimlneo   di  — 

in|,-i-ati ami     lliii-    to    atVonl    llie    lir~l     iin|inl-e    to    the    |iroc,->   ot' 

nlcrratioii.  l-'iinlirr  lantiil  iniiTo-ro|iir  ami  liartrriolouii'  csaiiiiiiatiolis 
arc  -till  llrrili-il  to  c-taMi-ll  llir  -|irrilie  rlial-artiT  of  llic-e  li-ions. 
l,ii-eal(llo  '  lia-  ri|)oilMl  tin-  iiiltivation  of  tlir  l\  plioiil -liarillii-  from 
the  iiillaini.<l  mino-a  of  llir  r|iiL;loni-  in  one  la-c,  Inn  lii-  rr|iort  i-  \vv\ 
ini'iiiii|ilrtr.  More  -ali-fariorv  i-  the  iTport  of  Sclnil/.-  a-  to  fmiliiiL' 
lliat  ori.nini-111  Imili  in  -<i-lion-  and  in  iiiltiirr-  from  llic  -wollni  lym- 
jilioiil    iioilnli-. 

'llir  o|iiiiioii  i-  lii'lil  liv  -oiiir  tliat    |Miicliomlril i-,  willi  ali-ir->-foniKi- 

tioii,  iiiav   ilr\rlo|i   imlr|irmlciili\ .  w  itlioiil    anticnliiit    nlccratii f  llir 

mucous  mcmliranc.  Condition-  of'  tlii-  kind  would  lie  comiiariililc  witli 
tlic  tvplioid  pcrio-tili-  of  llic  lonu  lioiic-  ,;nd  the  lili-,  and  cxaminalioii 
of  the  |)n-  for  l\  |iliiiiil-liaiilli  would  he  i'-|Mciall\   di-irahlc. 

The  trachea  and  the  larirc  bronchi  arc  ranlv  the  -cat  of  iirofoniid 
alteration-.  <icnerally.  at  the  liciuhl  ol'  the  di-ea>e  their  nuicon-  meiii- 
l.raiie  i-  markcdlv  reddciied,  eoveriil  with  -canty,  vi-cid  -ccrelion,  and 
the  -c;it  here  and  liicrc  of  -mall  cro-ioii-.  <  )nly  exeeiilionally  do  tlie-e 
heeome  dispelled  into  actual  nicer-,  and  IhiI  rardy  do  they  L'ive  rise 
to  perichondriti-.  nccro-i-  of  carlilat;-e.  and  |icrihroncliial  siipjiiii-atioii. 
.\  niimher  of  oh-erver-.  parlicnlarly  <  iric-inLi.T,  rejiort  the  occurrence 
lit  psendomcmhranous  diphtheric  depo-it-.  Tlic-e  are  in  any  event 
exlremelv  rare,  and  tlicv  have  not   yet  liecii  -nliiieled  to  thorouirh  study 

l.v    modern    ni(>lliod-.      'i'lie   occurreii f   c\ten-ive   tilirinoiis   traeheo- 

liroiiehitis  (Ki-eniohr)  i-  noteuortliy.  and  it  i-  to  he  di-liiiirni-hcd  eharly 
l)v  it-  clinic.il  coiir<e  froiu  true  dijihtheric  lesion-. 

I  /,',,■/.  1.1, „.  If..-/,.,  1S!I4,  liii.  \x.\i..  Nil.  Hi.  ■"  /'"./•.  Hil.  x.v.w.,  N...  34. 


^Bm-^ 


J 
I 


/'  f  ri/ui.iji;y. 

': '"^''  ^'^'■:'-  Ti,i.  i-,„„a ,,n,„. , i,,.vj„ ,„;: 

;,'';■" -;''.;'7---i'7-^'- '■■'--.  i--M,K,,,i.;.-,a,i r,i„.  ,..,„.,;, 

'■'"!''"'"'     ''>l""-|''---       Tl„      -,„:,ll,.,.    .,,,1     ,l„.     .,ull,M     l„..,„..| 

"" ^' '  '"•'■""•■'•  '''-''■-'^'■•'-K-ii.l„-„.,,|i,„,, „•„„., .„.,,,„,„„, 

"    ;""'"'"•-"..  an,|    -,.:„„.    -,.,.,..,i„„  T,,,,,,  i,.       W  i,  I,  ,|,.,  „„|„,i„    „,• 

'':""'    ''•'■'■•       ":"   ^"•■'■■'■'^—1    I" ■■■■>■    I un,„nia,    ul,i.. .„r 

■:;"■' ""^•^";  ""i'-"iy-^-iM....iui,i.  ,i„.  ,v,,i,„i,,  i,,.,,,,..,,!,,,,,. 

:'~" '"■ ,"'\''^'"'  '■•^- "" "—  '"■'"  -H.ii..i..,„iv  Mu.ii,..!  i,„.,„,i„: 

^^"""'-       '""'^"■^"    I'i" li f,-a-,.,    ,1 „,li,'i.,„    b„| „    ,:„. 

;V""' '7'-'^M'i.>i i-  •.-,! a„ .■  ,i„. i,.i:,;„„„„:.v 

I,ungs.-An..,.,|,.,,M;,ll,,ui,,,  ...,,,,,  ,„„,...„„,„ ,„„„,,,„. 

|irrtrr. 


"]"«'    tl„.  ,li,tnl,„ti,,ii   .,f  th,.  |,l,„„i_  ,|„,   I 


intcri-it\    iiri.  ..,'  tl,  ]•   •  .  .^.....11  [Mi;   iwdidii 

,^  _    '  .'  ■     .""''  '  .""■  '■'""ImoMs  i.ivM.Mt.      Tl,..  ,..„„,„|lv  sl,„rt  ,lMr„i„„  ,. 
'M'l I    l.'vr,.   ,„  ,.|,il,|,v„,an,|   tl„.    M.url,    I,.  "  '"""■""""" 

Jt      t         '7^ '"'"•"■•">•  --|"-il'>"  <■'-!..•.;,..  that  l.v,,.,>,a,i, 

''•'''''■'  ^:  7'''  ''--■'■'"'"""  i-  tl,.m  than  in  a.lult-  -I 

AniMiiir  ,|„.   |„|,,,  i„Ha„in,at..rv  ,„•„,,...,..  ;„   ,i      ,      '     •      , 

'■'•'> i'l    ''-'•   tn.   ,il.nnou>   ,nn,n  ,'"'""  ' "'" 

.•as.sat  tlic   f,J,„      If      i  ■         ,,  "''^  '"■'■'I    !'n-cnt    1.,  t,,,,,.^    i,,  si'!t 


'"'."i;""     ""■     '•^'•;inl<..l-W,.i,.h,s,.lhan,n    ,1 


l|llllC(l<VI|«.      „hil(.      th, 


CI     11,     ,,(■     I.-,.;     11  ■      I  'ii   riiiiiPCCllv.      wnc      the 

".-"Hx,.l.nf.,.t.„„s,H.,.nr,   ,.s,,...iallv  of  I>i,.,„..,.,,,„   ,.„„„. 

77,,  .v,   |'„ri,    ]fjj^,,  ._,        _ 

'  /-■.  nf.  ,      '"'•"  ■'"""''■■  '''-'""/«»,7™,   \Vi,.^l„u|,.„,   l^-U 

^^''■"'-^.  '«o..  „v,.,  „,,,,,  ,jj'^;;';  ;;;;:'-,;''-^-  •^•".  ^^^  ^ana  4. 


.Ji^ 


:'--f>lJ}'  ,     ^J_   r^ 


.^   iV: '-!-".-  =  -   =    "  <, 


^j:3 


,„„„i:..    .i.l.    M.v,...K.„.,i.n.l    -.:,,,lnl -.       TL  ^    I--! -.,•.,.., 

,,.,,.,...„  -„.l,or,....l,lvMu.l,..l:.ua. ..lU    ,1,:,.  an,   .l.lnn,,.    -.;,.,.„,..., 

;.„,    |„,  „„.l,.  ..i,l,    n^r^ni    I..   tl„ir   („.,,„■„,•,.      N-l    nnvK   „KMr,,-,-..|,„. 
ii,.,„.,,i„„  „r  ,1„    ,M,    -nri:,,-.   ..f.h-    Inn.uill    ..i-,.  .  ^n-,.n„n   .lu..  ... 

i,„,:,n.v  uf  tin-  ,un,,,lir:,.,a  v:,n,  .>    .n:,v    1"-  l^n-.-.H. 

In     ,.nv    in-,an,....    -n,. -    )-.  nn,,..,:..'     uln,   ,.    :.-     ..-    l"-" 

,„.„„i„„...,.    ,..,„.ralls    .".,.n,-    n>    lol.nhu-    fo.-.n.  i-    lonn.l    n,    l^Lar   t,.-n,. 

S.ill    1..-,    t,v.,nrnllv    -,a|.h,l."."vi.    pn.n.nonia    ai-l-ai-    t -nr   a-    a 

nn.nu-inHrlic.n    in   .-a-.-  nC  t,|.l,oi.i    f.  v.r.  .       .  ,     ,.      u,, 

MiM..l    inl-.i....-    ■■f    -nv|.l ■■■i    mimI    -ta,.l,vlo..„.v,    «m1,    l.anlln. 

;,,,,„.•  ,...-.. .vi.l..'i.l  ...■l.a-la..lvl....,......-..l..-.<ll..vA.   l-.ank.l, 

„1„,   .,',.   "On.,   .-a..    -av.l.ti..i..l.v  .l,a,    .1:.    ..-•.■...  n.....  ..t    n    im........ 

^,!„  a.ul  .v-nl.  ..f  .1.    l-ma,-y  l.,.alixa,i f  ,1...  ,y,.  ..... M..-   In-n  -1- 

l„„.._n,n-.    I...    .v.a.-.l...l  a-  .....    >>•.   .l........-t.-t'-l.         XM.-t  --•  a    .■■- 

,„„l-,.v  l..l.a.-   ,,.,....n.....ia    ...■.■...Ti...   .l...i..ir   tl..-  .■....---•I    t.v,.l.....l    l.v.r 

„,„    i„.    .,,,,..,1    !.v    ,1...    ,v,.l,.,i.l-l.a.ill..-   ..l<m-    i-    ^.1 1""    "■    -""• 

,,„.;.,i,„,     „..,.i,l.:,a...li...     .1.^'    ta...     .1.:..     --...-al     ....■-    ''l"''"^;     - 

',,..1,    a.- .:n„...i    i..    th-    li."-----.       I"    - '    .1--—  -K"- 

„,  ,,.    .,,,,1..   -..    la...    i,.    Ilu'   -li— -  '!->■  "V....  tl.-..^'l.  'I-    p..".'".— -'- 

,„,.„P„..l   1.;    lV,.sn..l..M()l.-.-va.i..n    l\.)a.,.M.v    h.aa.-l    l.o.-.lo...- 

Tl...    s......,..l    n...    r..,....-.-.l    1..V    Il..ns,...l..-«)l.-..,-va......    lAlX       w 

n,„r .vi..-i..^.    1....    tl..    l.a..,...-i..l..,i.-    .•-,-...•.    i-    i...'.;."l.l.'.^      <"-• 

1,,,,,    „a.l..  l.v  (•|.ant.......>M..  KinUl,.'.  I'..-.........,"  a...i  ...l..». 

,;„„.,vn.:,.-  i....-.i....>  ..fl.n,;:.:  ..r  i\u.r  i..  ..  Ma...  .-I  l.y,,.,-.a:...  ^,.!....- 

i.a.i..../...-    .v..,.    l..l.:.r    ,.............!..-    -l...'    to   ,1...   ,.........—.>,    n-v 

nn.l....l.....llv  1...   i..va,l,.,l   l.y   ,y,,l,..i.l-l.a..illi.      Al.l,....,l.,  ...  -.w  ut      ..■ 

.,.,,,    va.-i..n-  ..f  intla.n.nat..rv  .......liti....^  wLi.'l.  "-av  l.-  unhm<\   !->   :1.- 

;vnl,.,i.l-l,a..ill..-Jt  iM-"il'l''  '1-'  i'  •->  '•''-'^•' ='•'■'''■''''"'■  7''"^^^ 
v.,  ,hi-   t;,.-,n  ..!•  1....^   inv.,lv...,..-..,  if  it    -•..,•  ...-.■...-,  -.a.-t    «1"  -  v.tv 

,^..„  „„. ,,., ,■  ,v.M.  .>,.„.  ,„v  .lini,.,  / /'--  i.-ip--.  '^■"■'  »•:■■  ^'■"; 


'  Y'A/.s.-.   IV.ri-,  1>-'.T. 

T  K'l.A.H.r...Ml  H:,rri-.  .r^h"s  ll'fkn,^  Ih^/..   /i""..  1>^'-' 
.   -v     Kr.,„k,-1    /,,7.  /■.  klu,    Mnl..   Ha.  X.,  S.  4:i',.. 


I!,{,,r„i.i  III'-'/.,   it'^-  N'.    1- 
77m,....   I'l.ri-.   IX'.'-- 


=    1.  ,.'  .ft     .  ,    ■      .  /    ' 


/^:.>-'T4r.?^"<ttfa 


/'I  I  imiui;  y. 


\ 


\\ .      Aciiiniic'   lii-iiiliii/ii   ;iiiil   li,iciiriiil'i;.'ii-  r'|Miri- MH'  iiiiiili   nnili'il 
ll  ar  ii|i  till-  iiHi-t  iiidri'^litiir  :hi<I  iiii|Mirt:iiil  |H>int.      All  <>t  tlic  vaiidii" 


■'■  I 


III  llllliillla     llli'lltlnllMl 


K'l'Mniii)^    III    till'   iiiiii- 


ir,  lliiiii).'li  raiil\  ,  tn    I a|i: 


llllr     nf    irivill''     li-l'     I 


.1    al 


it    till-    Iiiiil:-.       Mila-tatir   al 


i^i-c — i'^     a,-- 


III 
,1 

IS  |>l 

1  H' 

■al 

iiiaii 

'III 

Mil 

iiiarv 

it  a  riiiii|iliiatiiiir  |i\  iiiiia,  liavr  al~i)  liccii  iili-ii\  ihI.     1 
i|i|iiar~   til  iicciir   -oiiiculial    inure    iVi'ijiii'iitU ,    -uiiicliiiics  as    tl 
it'    liiliar,    i-|iriaallv    lilniiinii-,    piiciiiiiiiiiia,    in    -iaitc    |inilnirlr(l 
iiiil     ill    |ii'i'\  iiiii-l\     ili'liilitatiil    iiiil 


Mil     t'cvrr 

lii|illirllt 

(■-taliiiii-i 

;riii;in'lii 

IC     -llllll 


III  iil-|iiiriil('iit    I  Miliiili-iii,  ami.  tin 
I    III'    a-|iiratiiiti 


ti'Mll 

■  if  I 


1: 

i-l-ll 

aliif 

ll     run 

\  ri 

.1  t'n. 

III    1 

hr   t'lii 

1    1 

iiinil 

nit, 

jiiilrii 

111' 

n-p 

irati 

irv  |(: 
ii-illit 

Lfl'l 

•111  111- 

111 

•,., 

-  am! 

1    III' 

<Tli-i- 

A  a 

-  Ill,- 

r|-\i 

■ll    liV 

lllltlnll     llia\'     ill 


ll  it'  tl 

i  atl 


ir    IlliillI 


itliriimi-  lit 


■airi-.  ili'ii 


tal 


i-,  III'  t'riim 
lit'  rarlilap'. 
Liil 


iilllirl-lcr 


111 


iiiiirrlia^ii'  iiitiiiTtinii 


the  I 


liviil 

iial-. 

ami 

lall.v 

— am 

1     this 

i-|i||i 

■iiiiiiii 

lia    ll! 

■   ihr 

,■   I.I 

piiti'iil 

h  i- 

nut  well    .•: 

the 

iii.iiltl 

1  ami 

[•aric 

-  will 

1  triiiLT 

aryii 

^"■■•'1 

lllrir- 

Spn 

iitaiic 

Ill's    JX 

,  lia- 

nut 

IK'I'III'I 

mil,', 

as  w 

.11  a- 

al-ii  a-    tlic    ii-ii 


It    lit' 


IS  III  (-.p<iial  im|Mir- 
t'  mii-t  vaiiiil  iiiij_riii. 
I,  iiiti'<tiiiiis  mat. 'rials, 
■ariHl  I'nr,  nr  mav  ari^c 
lit'  the  r.iinmcncrimiit 


ll  al. 


ival  ali-cc- 


iiiini 


lint. 


I    witli    |H-ri<'liiiniintii' 
an^rciic   nt'  the  liilii:-. 


I'lil    III    iiiv  .■\|M'ri('ii('i'. 


III.'  -anil'  I'.imlitKiii  in 


llir    -pliTii    ami    till'    Ivi.lni'y-,    i-    nut     rtir.'ly     t'.iiiinl     in    tin'    ImkIjcs 


it     tviiliiml    t'.'N.^r. 


\     ali-.iriit!.'n    ami    runlrai'tinn,    I'Vi 


Till'    intiii'.'t    may    iiii.l.ri,r.i    inv.iliitiuii 
ntiiallv    with    liralri/atimi  ;    ur    it 


may    iiii.li'rs.''ii    pnrnlriit    ur    cs'.'ti    ixaii^-r.^mnis    .li-int.^irrati.in,    },rcnrrally 
thru  with    llir  (lrvrlii|iiiiriit   ut    ('\iiilati\('   pl('iiris\',  i'-|M'i'iallv  .'iiipvcma 
rii.^    prriphiTal    -itiiatimi    mil    tlii'  w.'ils;-.'— hap.'  ul'  tli.'  ma 
iiil'ar.'is  ar.'  at  .m.'.'   iii.licaiiv.'  .if  tlirir  t'lnlxilic  orii^in. 
t'art,    miinil,    siit'i('m'<l    thr.imlii   arc    miilcr   sinli    cumlitii 
tiiiiml    in    till'    riyht  -i.lv  nf  the    liiart,  partiiiilarly  in    the 


ill.'  aiiri.'iilar   a|)p('mli.\.      Sii.'li    cmliiili     mav    li.'  (IcriN-.i! 
lari,^'  hran.'hc-  .if  tli.'   piilm.inary    .rtcry  it-clf,  which  ii.it 


a. lit.'  alt.rati.ins  ut"  the  intinia 


III  ca- 


's  of  tviihiiiil  I 


I'V.r. 


with     infar.'ti.iii,    sii.l.l.'ii 


ith 


til   Im'    li.irii.'    Ill    iiiim 


ijiirity 

nf   till 

'-e 

Vs  a  matter  ■ 

i.f 

ins    t'l 

I'.'.plcllt 

'y 

auric 

Ic  an.l 

in 

al.-.i 

fr.  nil 

IC 

i-arcly 

cxliili 

its 

In  c. 

•mici'ti' 

III! 

th.' 

cause  . 

-if 

nhi.'li    is    t.i    be    l.Mikc.l    fur    in    eiiil)ii|i>m   of   a    main    Imincli   ut'  tlu' 
pulm.Hiarv  art.'i'v.      The  -.nii-ec  nf  thi>  .inlinlii-  als.i   mav  he  fniind   ill 


the  h.art   .ir   in 


th.'   ll 


ll'ir.'     |)cri|) 


peril 


ilicnil    v.iii    .if  the    IiimK 


I'l.'iiri-y  ill  the  fnrm  nf  a  mnre  nr  le-s  exteit-ivc   til 
.lit 


inn. Mis  (Icjwisit  is 
lint  rar.'  a-  a  .'.m.liti.m  as-nciated  with  the  various  forms  .it'  pneumonia 
iiiniplicatinLr  typhoid  fever,  ami  iimlcr  -iieli  circunistani'es,  in  so  tiir  as 
pr.viou-  inv.'sti^ratiiiii  ha-  iliscl.i-cil,  i-  in  l,e  allrihiitcil  to  the  iiii.'ro- 
nrpiiii-m-  res|)onsil)lc  t'.ir  th.'  jmlmonary  disorder.  I-'ihriiioiis  and  s.ptic 
|)iiciiinnnia    als.)   lc;ul   at    times   to   empyema.      Serous  or   ser.ilihriiious 


F 


HH 


7  )  ril'flh    I  I  I  /  /.'. 


.;  '!' 


(•_•     ■  ''■1 


I 


Alllnll-    >'J'.t    iM-r-    (if  l\  |lll"i<l    t'lM  1-    ill    ill"     -I  nil  MS 
11     .H.lirlril.        'I'llr     [111-    Ml    llli-* 


plriirilir    .iVil-i.m^  nf  cMi-iili  ral'lr    iiMi il    aiv    iviii:iiU;il.l>    ran     in    llir 

,-..lll-.'   ..r    tsplM.l.l    f.A.T.  I' lnolllM-:,\    (H,  III-    .Mils     .  A.r|.ll.lll.lll\.   Mini 

^:,  iirnillv  a-    III"     -..III,  I  ..I    i.iinil.  Ill    ..r    -aii-iviiMii-    li,,  a!    .li-ra-r  nl    llic 

lull;;-. 

■rii,.  ,,;/,  ..r  r.acillii-  ivplm-n-  in  tin  -mm.i-  |,I,  iin-ii  -  ainl  riii|.\  .iiia^ 
,.,„„,,li.alin-  Ulili-hl  livT  li:i-  n.Miillv  Im.ii  .li-m- nl  l.>  I'' rank.  I,' 
l;,iiiliii-i  r,-  aii'.l  ..111,  r-.  l-ranU,  I  ,.l.-.  rx,,!  I  .a-.-  ..f  .iiii-v. ma  ani.nij; 
.-,1111    ,aM-    ..f    ivplL.i.l     I'v.r.      Cnllnr.-    Irniii     llir    piiriil.  lit    .■•IVii-iiMis 

-|„,u,.l    ill   Jia-'.-   I'..   I.\lili..-u- ;    ill  III,'  lliinl.   -Iiv|.|... n- ;    ami   in   llii' 

r..iirlli,  |.ii,niii.'<-,.,'.'ii-. 

Ili.lpkin-    Ii..-liilal,  lull    1    .  a-.'  ..I    ,iiii.\,  nia 

CM-.' .■..nlain.'.l  III,-  l\|.li..i'l-l'."illn-    iii\.r>    lai-,-    iiiinilMr-.       I!,  n,lin-iT 

li.i-  i,.i„,rl,,l   ■<  ,a-.  •  ..fi  ni|v\.nia   ami  ,.l'  pi,  nri-y   uilli  ,tVii-i..n  lV,,ni  llic 

.,^i„i.,,,..   Ill    7  ,.|    ulii.'li   ill.'  lvpli,.iil-lia.allii-  \va-    i-,.lal,,l.       II.     lia«  aU.. 

,.,,|l,.,.|,.,i    l:i  -iniilar  .a-.-.       Siill  -.'Vrral  ,.lli.  r  .-i-.-  aiv  .■..niaiii.  .1  in  llii' 

ljl,.,.;ili,iv.       Wliil,'    ill.'    I,a.-l.ri..l..,-i.-    .•saiiiiiiali..|i    in  -.  .III.'  ..f  llic  <  arli.T 

,,,-.-  niav  1,.'  ..p.n  I.,  .I..11I1I.  tli.  iv  .an  I .|n.-ti..n    tlial    in  a  nniiilMT 

.,f,,i-.  -  ill,.  iypli..i.l-l.a.illn-lia-..,'.iirr..i     l,.n.,  aii.l  il-  priinarN  .■li.il..f:i.' 
-i-nili.-aii.-.'  -..II,-  t'ailly    u.ll  .-lal.li-li.  .1. 

i-|il„ivnl,,-i-i-an  iiiip,,rlaiil  ,-,.inpli."ii  i f  I  \  jili..!.!  I'.v.r   .-p..ially 

tiil,..|v,il,,n-   .li-,:i-...f  111,     Inn-.       It    nr-  in  \aii.,ii-    f..ri,i-,  nani.'ly. 

a-  part   nianir.-tari..ii  ..!'  a  .•..nipli.-atili-   ^.n.  ral   miliaiv    till"  ivnl..-i- :   a- 
„,    ,l,.-.-v.    l..l,iilar.    rar.lx     |.,l,ar.    pii.nin.  mia  ;    in    lli.-    f.irni   ..ra.-nt.' 


a. III. 


I-  ;i  .liiv.'l    .■\a.Trliali,.ii   .111. 1    a.aitc    ili-- 


tnli.'r.'iilDii-  |i.  iilir..n.-liin-  ;  "r  a- 
^,.,„iiiati.,n  ..r  a  pr, -.Ai-iin-  api.al  liil,.ivn!.,-i-.  liilli.rl.,  piir-niiii:  a 
,lii^,rj-l,  ,.,,rr-,..  Al-.i  ill  lli.-.illi.f  r..iin-,  lnlMivul,,ii-  alV..'li..n-  ..f  -.nuc 
-taii.lin.j.if  tl...  Inn.-an.l  tli.'  I.n.n.liial  .^laii.l- .  .r  .iC  ni.nv  ivin.ilc  .-f-an-- 
inav  aluav-  I...  i;.iiii.l  ait.'r  .l.Mlli  a- ill.'  -,miiv.' ,  .f  tli.'  iv.-.'iit  tiili-iviiln-i-. 
AU.,  il„.',„vnrivii,v..f  tnl..i-.'iil..-i-  a-  a  niiN.-.l  iiir,.ti.,M  i-  int.iv-liii-, 
:„i.l  lia-  1m,  n  .•aivfiillv  -tnill..!  in  a  f.u  ."1-.-.  K-p-.'ially  in  ..;-.-  ..f 
lvpl„.i.l  pni'iitiHinia  lli..  tnl,.  ivl.-l,a.alln-  li.i-  Im.ii  f,.nii.l  ivp.al.-.lly 
t',„^,.tl,..r  xvilli  111..  pii,iini."-...vn-  .'f  Krankrl  ami  \V.i.li-..i:.ainn,  llicii 
iKiinr.illv  in  .•..njnm'ti.in  uitli  .■..rr.-p..n.linL:ly  .•.iiiiplii'at.'.l  lii-l..l.ii.'i.' 
.■..ii,liti,.ii-. 


ALTERATIONS  IN  THE  NERVOUS  SYSTEM. 

Il,    ,.,,nt..-t     I,,    till-    ni.irk...l     pn  .L.tninaii...-    "I'    .•lini.-il     in:iiiif.-ta- 
li,„i-  with    ivf.ivm-,'   t,,   til.'   .M.nli-il    mTV.,11-    -v-t..ni  in  ca-.- t.f  typlmnl 

f.v.r    piir-niiiL'    a    ~i-v.av    <• ■-.■.    il"'    analnmi.-   tin.lin--  aiv    .■xtivin.'ly 

.li-ht.       I).Mil.tl.-lv.  tin-    i-   line    t.i  til.,  lii.t  that  tli..    pi-i.timml    iwrvi^iis 


/,..,..  ,-,/. 


A',.-,  ./,   M.-i  .  \:»»>.  .N..-  !■-■ 


I-Mllnl.ni.y. 


llf» 


ili-'iiilp;inii-  arc  :illiilmi;il(lr  c^iii-cially  tu  a  'pcrilii-  Inluxiralioii  ilt|Miiil- 
riii  ii|Hiii  llir  I\  |)lii'icl-liaiilli,  aiiil  uhicli  i^ciitnillx  i;i\i-  li-c  \,,  a  Iniii^i- 
lor\    iriipii --iuri  u  ImpIIv  (li-|)|i,|n,i  lion.ilc-  lii-|ii|n;;i,all\   lo  llii-  iiitiii-il\    nf 

II  -     -\  III|iImI1I-. 

Cerebral  Meninges.— I'lic  dura  not   raivl\  |.i.-.iii.  Ii\|«fvmia 

illlil    I- •    |i  --    iiiaiknl    III!  lit    ailli(-iMii    to    l1ir    iiiiiir    -ilitiicr  o|    llu' 

-kiill,  wliiili  ill  tiii'ii  i-  till  II  1:1  ii.iall\  llic  -<al  of  o-.|Mi|ili\iic  (|,.|Hi-it-. 
riic    \:\yu-    \(iii>    aii'l    tlic    -iiiii-i  -   air   oricn    cli-i.iiili-.l    \vitli   dark    lliii<l 


hi. 


wliili'  tlic    loi'iiiatioii  o|'  tlii'oiiilii  aiilx-ars  t 


to   (Kclir     OIllV    CXCClltlOII- 


ihrii  at  a  late 


-ta'.'i-  III  ca-o  o|'  |iioiiai'tii|  roiii 


Tiir  pia-arnchnuid  i-  usually  tlir  -.at  ol  ((Iciiiaton-  iiililtr;itioii,  -li^rlit 
iililiiii--.  iiijici'    II.  and    aillic-ioii-,  ami    tliiic   i-  ii-iiail\' 


an  iiK'ira^c    in 


till'   I'liar   or    -liw|ill\     tiiiliid    > 
tlic   oli-i  i\  alion-  ot'   I'r.   Sciml 


■iiliiciilar     tliiid.       ^lu'Wi-   iiot(  Aortliv 


/c,    u  ho    iiotcil,  on    nil 


tioii  of  tl 


cro-co|nc   cxamnia 


liioiv    ,,r    !!■ 


■am  and    lacninuc.  of  ca-c-    that  iliiniiLr    life    had  cxliiliit.d 
|iroiioiinc  id    -Mjijitoin-   of  ni<iiiii-iii-.    in    addiliuii    to    tiic 

"i"'"-'"l'i'"    a|i|.raian.c-     iiiciilioii,'d.     a     -inall-crll     infiltralii f    tjic 

iiMniiiLir-   and    a   .•ontiiinan.v   of  tin-    |,i,,c,  -~   aloii^'  tli.'  vr-.-l-    into  tlic 
fciiliial    ti~-iic. 

Siiliaraclninid    iiiciiini;cal    licinoi-rliairc- 
nicl    a-   a    rate  coiidilion,    and    later    liy    llo|]'inaiin  and  ( 
appear^  that   they  may  oceiu    at  an  early  -taue.  a-   dcmon-lratcd    \>\    tli 


ucii'  caih   (le-cril 


Mil     llV    I    iio- 


irio-iiiirir. 


It 


■1    e;|.,.-   ot     (i 


■I'    ll 


^er,  who  ol>-er\iil  them  a-  earlv  a-^  tia-   -ceond  ueek 


le  (ll-ea-e. 


I'lirnli'iit  een  liral  and   c'crcliio-piiial 


incninLjiti-  are  inciitinncd  cxccp- 

llv 


'i"i'-ill.\     ii'    'lie   earlier    literature,  hut    hax :lv  ivccntl 

l""i"''l  "III  "II  aecimt  ot'their  clinical  -ii.riiili,.ance  (  Diichck,  ( 
Uiilil,    I,e\d,ii,    Krh,    ('nr-cliniaim).      'I'Ik -c 


V  iM'cii   -iiicia 


inc~-meer, 


lllivt 


ctil|p|ja-i/i  i|. 


c   alle.'tioii~    niav,  as 


I    hi 


lira- early  a-  the  tir-t  week  ol' the  .li-,a-c.      '|'| 


lev  raiciv 


Iiriiiinate    fatallv.      Tl 


le   \ailctie~    that 


the      fehli 


e    iicriod    or    i\en    >1 


rtiv    afl.r    ilcl 


Iter,    toward    the   cik'    ot' 
er\c-cence,    are    t'ar    niiirc 


-evciv,  and  tlie\-  more  frec|iientl 


lioii-  extensive  and    iirotliiind   e\  id 

til"   firm  of  lil.riiio|iiirnleiit    iiitiltration   ,,f  \\ 

•  iraclii 


|ilently  ci>iiie  ti>  anto|i>y.       I'llder  llle.-e  coiidi 
em  e-  ot'  inllammatiiiii  ot'l( 


le   <'erclir 


en  a|i|)ear  in 
d  and  sjiinal  pia- 


ii'lil.       Wlielher  the-c  proce-.-e-.  ale  identical  .•tiolojri,.;d|y  ,„•  ;,fc  (,( 


vailed  on-,,,  j,  i„v,,lve  I  in  doiiht.  ,i>  thoroii-h    lii-toki^ric   and    I 
l"!:ic   -tiidie-  ar, 

.ft 


lactcrio- 


yet  uantini:-.       It  i-  not    impiohalilc   that    in  a  porti( 


01  tile  ca-e-  the    IkiciIIii-  of    Kh,  ,-t|i  i-  tl 


le  sole  or,  at  Ica-t,  the   predonii- 


Vrrhnv.ll    ,1.    C, 


.U../.     Wi.v-l.M.I.M.     Ii,l. 


-i';'i  iiiui  n.ii. 


' f'Ttv  I'n.iri  Tiiv  -.•r\ii  >■  iii   Ilici.l.i 


\  ..  S.  4i;!i  aiiil  r..n.iwii.i.'. 
Weill'.  Arch.    f.    khi,    M,;/  .   Md. 


'•ilk*'   '■ 


120 


Tvrii'iin  I  i.vi.ii- 


,„„„  ..x.itin,r  ...-.t  „r  M,,.I-m:..io„.  1,.  la...  v..Mrsatl-.M  D^wumu. 
,..,«...  1,MV..  I..TM  iv,.urt,.a  i..  "Inrl,  iIm.  ty,,h.i,l-l.arillM-  ^^a.  in.lat.-l  ... 
,„,„„,„,,  Tl,..~..  I:av..  l.,.n  r.-ll,,.,,.,!  M,.  ....Inly.  I'.H.M,  l.y  llnt- 
„,,„„'  \M  a.l.li.innal  raM.  l,a-  laflv  n.vunv,!  i„  .li..  .I<.1m,~  I1o,,U.m. 
|l,,-,,if,l       In  oil     r  ,-a-..-.  |.ar.iriilarlv  in  th.-r  ui.h  a-n.ia.r,!  Iil.nnou. 

,„„.n,n,.Mia.  .lu.,v  i~  ^ 1  ^.-n...l ..-i'l"-'  tl-  lM-ank..l-\Vri.-li-.ll.an,u 

,|i,,l„,.,,,„-  ..  .1,,.  -■an-ativ..  tar.,.,-.  Still  ...h.r  .-a-.-  a.r  ...  !.•■  atfil.- 
,„.,.,  i„  .,11  ,,rol.al.ilitv.  ...  .!..■  .■N'i'.mir  M^vn.  ..f  .n„.  (..|.i.l..u,.)  .vvl.r..- 
M.iual  .n.i.in-ili-  Al-^»1  tV...n  i^.h,...!  l.a....ri..l..;ri.-  ..1.-.  rva....,.-.  .!,.• 
,;,,  ,i,at  n...nin-iti,.  -vn,i,...,n^  a.v  ..n...nn...v,l  wi.l.  .v.narkal.l.'  t.v.|n.».r 

i„  ,,,-,.,  .,f  ,v,,h.,i.l  trv... MMTin^^    In    i-la.v-   an.l    a.    ti,n..>  xv  li.'.v   1....1. 

.11.,,,. ,.,.ivl.n,~|.inal  uH.nii.-ili- an.l  tyi.t,..i.l  t;.v,.-— i..vva.l  ...-vlhci- .. 

,U„  in  fav,,,-  ..r  tl.i-  vi,  w.^       It    i-   .....l....l.f.l    tnK.lly  .La.    al-..   ~..v|....- 

,,„.,.i    .„.  .,ai.l,vl„.....vi    al..n.......    in  ll.-    '■...•in   ..f  a  n,ix...l    .nl.rl...n  wi.l. 

.„1,„,.    „,i,.n,-.„-a..i-.n-.  .nav  -iv,.   li-..  ...  pntnlcnt    .n....in,^,t.<.       lin-    .s 

,1,.,  ,.a-..  .-,..viallv  a<  a    |.a.-t    .na..if.-.a.i..n   ..f  (■...npli.^a...!-   m.,.1„  .ania, 
1„„    i,    ,„nM    1...  ...npluM/..!  .l.at  ...ily  a  -mail   inin..iily  ..I   all   ...-<■>   .-t 

,v|,l...i.l    f..v,.r   .■..>n,,li..a...l    l.v    l.v."'ia   .■xl.il-it    .lii>    l...'ali/.a....n. 

■       \„.,.l,..,-    i,n|...,-.an.  va,.i..v  .,f  Mr,.,..la.-y  l.n.'nl.i..    .n,t.,n..M.,s  ..  .I.a. 
,;,ll„win.r    ,.n,-nl,.n.     intlanuna.i..n    ..f    .!..■    -ni.l.H-    var.    wi.h    .n..nn>...- 
,,l,l,.l,iti„  H.n,<-.lu-..M,l...-i-.  a.i.i    .■a.'i.-  .-f  .li.'    j'.tn.u^    l...n...       1.    i~   t  h' 
;„„,,.  ,„„.„v,„.tl>v  tV..,n  ,1...  fa...  .l,a.  tl,.'  atr.....i..n  ..f  .l..'  r■^y  ,-  .....  .■.nly 

„v...']....U..l  .l...-inL^  lilv  in  tlw  l..-..li.nn.lly  -.n,.i.l  .t  .-..ini.l.t.ly  .•...na...... 

'"'"  Will,  n.^anl  ...  .!..■  •■..n.liti....  "f  tlu'  cerebral  tissue,  i.  may  l.c.  sai.l 
,),„  i„  ..aM^,  of  .v,.l,..i,l  nv.r  i.  l..'.-...<  ...>  ...n-tan.ly  n  .n.T.ntr  L's-.-ns 
.,,  ,.ha„.,..  i,.tin,at,.lv  a-^...aa....l  wi.l.  it.  Hnlil  '  .■n.l..av.„v,l  ...  ..>.al.- 
\\A^  .vtvLral  ...l.ana  wi.l,  .■....-.•.■n.iv-  -..l^'ni..^  ..f  va.-yn.ir  .l.'^.xr  as  a., 
ah<.,.,ti..n  j:..n...-allv  ,.,•,.-.....  'i'l,..,-..  i-  ....  ^-nl..  .ha.  .I.i-.  a.s..,..at...l 
,.v..n    with    ......l.n.t-    .lila.a.i..,.    ..f    .!..■    la..n.l    v..n..M.O..-.   ,-    .l.n...... 

-I.al.l..  in  n,a..v  ...-.•<.  F...al  ...H-.-in.:  i  <|"it<'  v:U':  an.l  wh...  .t 
.,.,,„..     i-  tlu-   n.>nlt   ..f  tlw...nl...H.  of  th.'   .•'■.vh.-al   art.-.M..^   .hat    l.av- 

,,,,1..........  .1...  .h.p.n..fa.i....   ,Hvvi..M-ly  .ncnti-.n.-l  (..Mil.Tat.n^  .....ar....'- 

iti-)  or  ..f<'oairi.lati..n  in  ......  .-r  m.'n'  .•.•.■. ■l.val  MnUM-  ...■  \:n-^v  vcn.s. 

M,.vn,..-t    ha-   -•all...!    a.....ti..n    .„  a  y.■ll..^^  i-h-hn.w,.   .h-...!...-a......  ..I 

,1, n.h,-al  .....-..■x,  tl...  -n.-fa.v  of  .h-  .■o-,...n.  M.^ia.a,  .h.'  ..|.ti.'  thalann. 

atul  th..  .•...T.'.'a  .,na.l.-iir.....i..M.  whi.h    h.'  wa^  al.l..   ...  .-'a-v   .n..T..-...,n- 

Sr.-  ;.i-i   \V'>lil'  1  ' 


'.'n„;)l''''ri'u-.- aL'w. .-..■hai,  a..  .i.-i.i.-n-  i-i  Tm.Ih.s,'  /.-/./.  -"-"■  ■"-'- 


1H58. 


MumMmmrwi 


rMii'ii.iji.y. 


121 


rally  til  a  ililfii--('  ydlowi^lr  di-colc. ration  ami  acciiiniilatiun  df  lirnwiiisli 
|(ii:iiiiiil-uniiiiilr-  ill  the  iicrvdii--  cli'iiiciit-,  (>|pccialK  in  tlir  L:.iiij.r|  ion-ceils. 

Tllr   ..lltjill,-.   nfllir  ,-,l|~   !«.,•,, Illr  uhlitrl-atcll.  a-    I  lotriliallll    al>n   (ilMTVcd, 

HI  lliat  liiially  tlic   clI-lMMly  i~   ~lic,\vii    iiiili-tiiK-tlx   ami    |priiici|(allv  fn.in 
h-   |ii;:iii('iit-<'c)iit(iii. 

I'rriiliar  rniiiHl-ci'lJ  acriiiiiiilali<pii<,  i-|)iciallv  in  the  [.crivaMMilar 
lyiii|ili-|ia.<-.  Iia\<'  linn  ,.li~,r\  rd  l.y  \;,u  l;r.kiini:iiaii-.ii  and  l'(,ii(,ll'. 
Till-,,  aiv  liclirvcd  t(,  \,r  ,a|ialilr  n\'  iirmtratinu-  tlic  ncrvc-cclls  and 
raii-iiin-  thrill  t..  iiiid(  rm,  df;rrnrTaii,,n.  'I'Im.m'  nli-cnatiniis,  wlijch  arc 
at    luv-ciit  ditliciilt  of  iiitcr|irctalioii.  have   heeii  eonlirnic.d    Iroin  various 

- ■'■'-   (l>nl<e  Carl,  of  l!a\-;iria.    I'.la-ehk,,.   and   otliia--).      IIcnioiTliacrc 

into  the  -iih-tanee  o|'  the  hraiii  a|>|iear>  to  he  extivnielv  fare.  I  liase 
oli-erved  only   l;    ea-es  ,,f  ihe    kind.        Ali-ee~-  of   the    hraill    ocelli-,  oera- 

~ •'".'■■  ■!-  ■•!  H'(|iiel  of  |iiini|(.|it    inHaiiiiiialioii  of  the  middle  ear.  or  as  a 

r.-iill  of  iiieta-ta-i-.  In  ,,iie  iii-taiiei.  I  have  oli-erved  -iicli  a  i^ondition 
111  eoiim.etlon  with  ucm^ral  |)y,.|iiia  in  the  -e.|iience  of  a  putrid  lie<l-s.,re, 
and  111  another  iii-tamv  in  eoiinecti<in  with  alisce-s  of  the  liinir. 

Aiialoniic  alteration-  in  the  medulla  oblongata  ami  the  Spinal 
cord  ari.  aliiio-t  iinkiiouii.  K  liniinell  has  ol.served  i'  , vises  of  laill.ar 
li'inoirhaire.  One  ,„-,.  has  oeciirred  in  my  experience,  haviiiir  sviiip- 
lom-  of  acute  Imll.ar  paralysis  and  tcrininatiiiL':  fatally,  in  which  the 
antop.y  disclosed  Hiftcniiisj:  .and  capillary  lieinorrliaires  into  tli-  tissue 
of  the  iiicdnlla  ol)l..iio;;,ta.  .Mi.roscopic  examination  was,  initortimatelv, 
not    made. 

^\  ilh  re-ard  to  the  spinal  c-ml,  tli<.  statement  is  cncnintered  tliat 
I'   "Itcii  evhiliits   hyperemia   and  also  a  liypiTeniie  stat..  of  its  nieninjres. 

In     isolateil     instances    Cei    of    myelitic    and    espe,aally    the tirr.iieo 

"I  'nvimis,  ,il,e.|  anterior  poliomyelitis  (Shore)  have  li.vn  mentionwi. 
In  ..lie  case.'  in  which  the  ,onrs,.  of  an  attack  of  tvplioi,]  fever  was 
'l"Miiiiated  ev,lnsivcly  l.y  spinal  symptoms,  and  prese„t,.,l  ,he  clinical 
l'"'nie  of  an  acute  .is,.emlin^r  (Landry's)   par:ilysis,  numerous   tvphoid- 

''•"■'"'  ' '''  '"•  'I''"i'MWtratcd   microscopically    in    tn.nsverse   sections  of 

''"     ^l''"'''    '•"'■•'.    •""1    '•"iild   I nltivatcl    also    from    its  tissue.      In 

-tru.tuiv.  th..  .•ord  presented  iiisiu-niiicant  alteriitioiis  onlv.  The  case 
-Im'1>  lidK  up.,n  ipiite  a  si,„ila,.  one  of  Lei.dct's.'  presentin^r  svrnptoms 
"t  ■I'litc  [.andry's  paralysis  diirinjr  e.mvalesecnce  from  a  miid  attack 
"t  lyphoid  t;.ver.  wlii,.h  t..rmi,iated  fatally,  an,l  which  upon  p.ist- 
'n..rieiii  examination  exl,il,ite.l  no  material  .■lian,ir<.s  in  the  spinal  cor.l. 
In  another  ,.ase.'  also  sliowiu-   the  clinical  eonrse  of  an  acute  asc,.iidiutj 

'  riii--rl,,nMnn.    (>,•/,«»,//,  ,/,  C.,,,,,^  f,  ,„„.  y,,,i     ]^^,. 


TYl'iiniit  ii.VKi:. 


,,an,lvM>.  ..ipillMrv  lurnorrlm-.-  an.l  aivn-  of  .,,ti.ul.>- vviv  tnnn.l  it. 
tl,r  iHclulla.  T1m>  l,a.l.n(.l-.ui<'  .•XMii.ii.ali..M  in  tlii-  .m-c  iimvc  lu-al.v 
n-iill-.       Kiiimncll  '  lia-  nj"'!-!.-!  a  riiiiilar  caM-. 

Filially,  SliilV^  lia-  iv|h.iIc<1  a  caM'  uitli  a  vcrv  Miiiilar  clini-'al  n.iiisi', 
l,ut  uiiidi  xva-  v.Ts  a.nic,  .l.atli  ...■.iimn-:  in  ci-iiKcn  lionis.  The  .a- 
aniiiiation  uftii.Tnr,!  in  .In-  ..!>..  >linv  1  an  a.Mitr  i,rin..rrl,aLnr  transvcr>c 
n,v,.liti>  at  ti,c  Irvrl  ..r  tlir  ronitii  an.l  litth  .vni.-il  >cL:n,..nl>.  Cnltniv. 
in"tlli^  ca-r  xN.iv  aKn  n.-ativr.  All  of  tlu-c  anatcnir  .  ..n.iiti..n-  mn-t 
|„.  ..,,i,-M,T...l  a-  .•xt.vnu.ly  raiv  a-  •■oinpaiv.l  with  the  \m-v\uy,  nut 
,„„,,„.n...nlv.  c.f  niark.''.  -,.inal  .vinptmn-.  In  tlii-  .•onn.rtion  tli.  iv 
..Nl.tsa  -ivat  (Irli.icn.y  in   ili.'  >tn.ly  ..f  typlioi.!   I'.^v.t  at   tlic  antop.y- 

tal.lc. 

riir  peripheral  nervous  system  likrwi-r  lia>  K.vn  lait  raivly 
MiMlir,!  in  .•a-..-„f  tvplini.l  i;.v.T.  In  a-oriatioii  «itl.  -rrtain  .•lini.'al 
,„anii;-I  ili..n-  tl,r  anatonii.'  Ir-ion-  of  |.aivi,ri,yinaton-  .■.■iiriti-  l.avo 
h,,,v  ai.a  tli.Tc  iMrn  tnnii.i.  at  linu-  tln-o,i-lin,it  a  ^^\^v  .li^l^l.ntlon 
(!'itiT~   and    Vaillanl). 

Alteratic-  -■  in  the  Organs  of  Special  Sense.— I.iitlc  l.a< 

hitlurtu  l,r..n  l.'arn,.!  aiialoinirally  with  rruanl  to  the  cyrs  whirl,  .■lini- 
,.allv  oxhil.it  variou-  .li-tnrhaiir,-.  TLvration  of  the  -•onifa.  inti~.  an.l 
i,i,lo,.hon,i,liti-.  an.l.  in  i-olatr.i  in-tanr,-.  optir  nonnti>  have  Wvxx 
„l,M.i-vc.l.  TIh'  .■hanuv-  in  the  .'ais  have  Imtii  nioiv  fiv.,nrntly  an.l  inoiv 
thoron-hlv  >tn.lir.l.  Alth..n-h  hy  no  nivan-  all,  at  least  n.o-i  of  tho 
,li-tiii!.ainr-  of  thi-  oi^an  a.v  attril.utahl.'  to  ..xtriiMon  of  -■aiarrhal 
„„,1  nioiv  ,,1-ofoniMl  ,li-lnrhan,r-  from  the  na-o,,harvnir,,,l  ravity,  th.'  ton- 


-il-,  anil  a.lja.'cnt    -tructnrr-. 


Thti-.  catarrhal  .•oiidilions  of  the  iiuk'oiis 


,n,,„|,f;inr  of  tlir  Kn-ta.'hian  luho  and  the  tynipanw  .'avity  atv  anion^' 
thr  nioiv  ,.o„inioi,  roniplicatin,,-  At  tinw  -  ,.nnilcnt  .■atafrh  of  th.^  in.d- 
,11,.  ,,„  ,„-,ai.--,  wiih  p.rforati.M.  ..f  the  tynipanir  nimihi-anc,  and.  fiirthciv 
,„„.ul,.nt  atV.vtioii-  of  adia.M.nt  -trnrtnn-.  .-|M.,.ially  of  th.^  -vUs  of  tlu" 
,n:,-toid  pro,.,.,-,  th..  nlatrd  vein-,  an.l  tlw  a.l.ia.vnl  MiniM.-.  Diphthcn.' 
atr...ti.m-  .d  Ih-  Ku-ta.'hian  tuh..  an.l  .>f  th..  n.i.l.lh.  vm-  hav  also  luvn 
nhxTv-.i  r..p..at.-.lly  a-  th.^  inniu.liat.'  .■M.^n-ion  of  similar  pro.rs^.'s  in 
thf  na-opharyiiL.'.'al  -tvn.'tMn-. 

ANALYSIS  OF   THE  INDIVIDUAL    SYMPTOMS;   COMPLI- 
CATIONS. 

Th..  .■lini.^il  pi.'tnro  of  tvph.-i.l  f.v.r,  s..  ..xtfa.n-.linaiily  varial.l.'  witii 
,T<rard  to  -..v.fitv,  .Inralion.  ixn.npinir,  an.l  -l.v.lop"""!  "•'  t'"'  i'ldivi.lnal 
-vnipt.uns,  a-  wi.jl  a-  t., -.in-.ls   an.l  ...•ininali..,!-.  .an.  ..n  th.'  wh..h.,  he 
'  .  /,.,/.  ,-.  hl.n.   M,.l..   IHSI,   li,|.  ii.  ^  Dr.,1.  . I, ■■/.../■.  kin,    M.,1..   liJ.  Ixvii.,  1!«H. 


syMl'l(J.MS  AM)  (  iiMl'J.ICATI<J\S. 


1'2.'{ 


;illr 


il)iitcil    to   twi)   i)riiiri|ial    f:i(tui-~,  namely,  tlic   vital   activitv  of  the 
typhoid  \  ini-  ami  it-  .llrci,  n,,,,,,  the   Innly,  ami  the  iiidivi.lual   reaction 

of  tlie   patient.      Wliii ir  vie\v>  witii    iv;:Mnl   to  tlie   m ml    t'letoi- a 

n-iilt  of  con-tant  eiianjieand  ^^-adnal  evolution  of  clinical  kncnv  lc.|o(.__ 
arc  at  the  prc.-ent  day  extended  and  deepened  in  ail  diivction>,  tlie  Mm, 
llie  i-ilation^  of  the  typiioid-iiaeillii-  to  the  eoniplcte  picture  ot'  the  di- 
c.i-c  and  it-  individnal  -yni|)toiiis,  is  still  in  it-  incipieney  in  spite  of  a 
lar-e  iiMinherof  i>olatc<l  liicts.  At  present  it  may  lie  delinit.'iv  -lated 
tliat  the  ctfects  of  the  ty|(hoid-iiacillns,  viewed  .■ojic-tivelv,  eon-i-I  in 
it-  local  and  it>  jrencral  nianifi'statioris.  The  latter  i^  attriUntahle  c-scn- 
tially  to  the  toxins  c-enenitiMJ  l,y  the  Nacilliis,  the  carlie-t  kiiowled-e  of 
wliich  we  owe  to  I',rie<rer  and  Friinkel.  In  ad.iitioii  to  tlie  elVect^  of  the 
liacillns  of  KI.ertii,  tilos'  of  otiier  patlio;r,.nic  micro-or;,r;,iii-ms  are  dailv 
hecomiii-  more  important,  heinj;-  exhiliitcil  alone  .,r  in  coinl.ination  with 
the  firmer  in  certain  or^-.-ins  or  tmn.p.  ,,f  ori,r;ins.  ( '.msidere.!  stri.'tiv, 
only  the  tir-t  uronp  of  sym|.tom-.  -honld  at  the  present  day  he  inelnd("^l 
in  the  actual  typln.id  di-case.  while  the  c,)nditi(,ns  depdnhVit  parti.illv  ,,r 
e\cln-ively  upon  .itlier  infcH^tions  a<:ents  are  to  he  .'on-idered  as  <<,mpli- 
cation<. 

Al-o,  hi    the   prehacterioloui,-  perio,|,  .•omplications  and    se(|Uels  were 
con -idcr.'d  apart  Inmi  th,' actual  symptoms  of  the  .li-ease,  ;dthouirh  fr.un 
"ili'i-  pnint-  of  view.      At  the  present  day  the  pr..vious  divi-ion'appears 
'i'liic  arhitt-ary,  hut  we  are  unaMc  to  ivpla.v  it  with  anythin-  better.    If 
=ni    attempt  were  made   to  in>ist    upon  siieh  a  divi-ion    from  the   m.Ml.rn 
>tamlp,mit,  the,, hjc'tion  would    at    (,m'e  aris,.  that    the   present    state  of 
I'acierioloui,.   invc-ti-.,tion  of  typhoi.l    fev,,-  i<   l.y  no  mcan<   sn.'h  as   to 
.Mi-lity   a  reparation  of  the  actual   syn,pt,,ms  of   the  disca^.  from   the 
<""M'li'""i""-      In    d,.tail    much    that    i>    m'w   and    surpri-iMi.r    mav  ho 
l'.-oui:ht  forward.      A   whole  seri,s  of  alten.tions  that  until  re.vutiv  were 
■■'MKi.len.l  as  cornplicatini:  au.l   in.l,.pcndent  .,f   the  tvph,.id   ir,,nn  are 
now  reeoirui;,,.!  as  mixc.l   infl.ctions  of  typlioid-|,.i,i!li  and  other  patho- 
ircmc   ini.a-,.H,rj.ani>ms,   or    even  depemi,.ut    upon   the    fyi.hoid-hacillus 
:'l"ii''.      It    may  MitJic..   in   this  coinKrtion   to  n^fcr  .mlv  to   the  piindent 
|>ioccs<es  to  atf.vtionsof  the  hones  and   joints,  to  ••ertaiu  form- of  pu..u- 
""""^'  "••'!  I>l<'>'Htic  ..Uhsions.  a-  well  as  to  some  manif,.stations  on   the 
I'art  ot  the  n.rvous  system  and   the  h.art.      Fml.T  existinur  conditions 
I'-Hvver.  It  will  he  better  in  the  followinc-  ,lcseripti..n   to  abstain  fron,  a 
n^nd  separation  of  th,.  co.upli.-atio.,.  from   the  .-u'ttial  symptoms  of  the 
-li-nse,  and  to  t.vat  of  both  toj,M.th,.r.     In  so  far  as  this  mav  be  possible 
■MU   ,.tfo,t  w,ll    be   ma<K.  topt-esent   the    ^■..^■ious   pro,.esses  as   spe..iti,-   al 
pnre  •■omplications,  or  as  mixci   infc'tions,  as  this  .lilfcrentiation   is  of 


s-*-*". 


'% 


w 


I -J  I 


ryi-ii'iin  ii:vi:i:. 


(l(<i-ivr   iiniiiirtaiici'  i'l-;  tlic  niiii[irc!itii--i'.ii  "f  tlir  ili-c;i-f  ^I'licnilly  ;iii(l 
tor   it-   t'mlluT   -liiiK. 


ALTERATIONS  i:     THE  EXTERNAL  INTEGUMENT. 

Siiiir  --tiilciiicii'-  willi  rci;anl  In  tl ulitioii  of  the  i-\tirnal  iiitctru- 

lliriit  ill  ra-r-  (■!'  IV|)iiniil  level'  liave  been  made  ill  llie  (loenptidM 
III'  till'  i;-eiii'l'al  cliliieal  pieturc  anil  llie  aiiatniiiie  alteralii  111-,  'I'lie  -kill 
in  all  stajres  of  t\|)lioiil  fever  exliiliils  variou-  inanife-talioii-,  iiiiportaiit 
from  a  diairiio-tie  -taii(ii>oiiiI  a<  well  a>  in  llieir  Keariiiu  ii|kiii  tlie 
(■nurse  ami  tile  tei'iiiiiiatioii  of  tlie  ili.-eaM'.  One  of  the  mo-t  frei|Ueiit 
and  iiio-t  iiii|iortaiit  i~  tlie  n^eola.  'riii>  lia^  iieeii  -|ieeilieally  desitr- 
iiated  a-  the  tv]>lioii|  ro-eohi,  and  with  what  |iro|iriety  will  he  -liowii  in 
the  liillowiiiL.''  statements. 

The  roseola  (taehe  msec  lenlieiilaii'e,  I,oni-)  a|i|)ears  ii.  the  form  of 
small.  I'oimilisli,  well-eiremii-er'hed  nd  spots,  vaiviiit:  in  -v/.v  from  that 
of  the  head  of  a  |)in  to  that  of  a  lentil,  and  always  sliixlitly  elevated, 
whieh  fide  eoiii|)letely  on  pressure  (liest  made  with  a  jrlass  pleximeter) 
at  everv  staiT"',  mid  thus  are  shown  to  lie  purely  hyperemie.  I'ale  red 
and  pnnetate  when  they  tir-t  appear,  the  roMola'  rapidly  heeome  larfrer 
and  darker  in  color.  They  are  almost  always  di-erete  ;  here  ■••■  ',  there 
twii,  rarelv  -everal,  coalesce.      They  ajipear  first   in    the    seen  .t   ol 

the  tir^t  Week  or  in  the  l>ejxinniiiir  i>f  the  second  week  ol  t.  ,■  dl-i  se. 
Cases  ill  which  the  exaiithem  apjiears  later,  not  hefire  the  midille  or  at 
the  end  of  the  second  week,  arc  rare.  Kxceiitionally,  riseohc  appear 
carlv,  from  the  second  to  the  liiurth  day  of  the  disease.  I  have 
ohserved    this   e-ipecially    in    women    and    children 

The  roseohc  api)car  first  ili«>n  the  chest,  the  alHlomeii,  and  the  hack, 
rpin  the  hack  they  often  apjiear  twelve,  even  twcnty-fnin-,  hours 
earlier  than  upon  the  ahdomen  and  the  chest,  and  in  the  situation  first 
named  tlicv  are  not  rarely  somewhat  lar<;'cr  than  in  the  others.  From 
the  trunk  the  roseoloiis  ern])tiou  <rcncrally  does  not  extend  further, 
althiiueh  in  exceptional  instances  it  may  invade  the  arms  and  the 
thifxlis,  and  (|nite  exceptionally  the  fiirearnis,  the  dorsa  of  the  hands,  the 
leir-.  and  the  feet.  Such  extensive  distrihution  n|«>n  the  extremities 
almost  alwavs  presiip|xises  a  rehitively  dense  involvement  of  the  trunk. 
It  niav  he  accepted  as  a  rule  that  this  part  of  the  hody  is  |)referalily 
and  most  dciis<l>.  the  seat  of  the  roseola',  and  their  numher  diminishes 
proirri's-ivelv  the  fiirth'T  from  the  trunk  the  alfected  jiart  of  the  hody 
is  situated.  !u  a  e.'ise  ill  which  a  ro-ieolous  cxantliem  wa<  more  dense 
upon  the  di~tal  portions  of  the  extremities  than  iijion  the  proximal  |)or- 
tioti^,  and   even    ui>on   the   trunk,  I  would   from   tin's  alone   have  some 


.vr.l/y/'/.l/.S'  AM)   (OMVLKATIOSS. 


lir-it;iiiiv  ill  niMkiiiL''  .'i  ili:ijriiii-is  ot'  tv]ilwii<l  i'cvcr.      IvomhIm'  vciv  ninlv 
:i|i|";ir   ii|miii    tlic    ta<c.      ()iilv  cxccptiiiiiiillv    li;i\r    I    t'iiiin<l    tlii'in    n])(iii 


Ullil    cvili    at     tlic    lower    Imn 


Icr    of    ll 


ic    iiilcrior    iimxillarv 


III  iriiicral  anil  in  ((uniiaiiMHi  with  llic  cITIon-icciiccs   of  dtlicr   infW'- 
liiiii-  ilisca-c--  tlic  rn-(ul(pii>  cxatitiiciii  ot'  typlioid  fever  is  not   ai)iiii<laiit. 


W 


leii  It  ilrvelo|)-   -iiiiiiltaiieoii-ly  III    larf;'e    iiiiniher  anil  ill  j^reat  deii-itv 


tlie  a|i|)eal'aiiee  i  reateil  i^  -trikiiiu,  ami  jrreat  care  in  i!ia;;no-i»  will  lii 
re(|iiire(l,  as  eoiifii-ion  willi  <itlier  iiit'eeti  iiis  (ii>ea:-e>  is  reailily  |M)ssil)l(' 
Tlins,  I    have    iiou  ami    then    oliserved    syjihilitie   ro>eola  witii   erujitivi 


li\i-r  ail' 
111    t1 


i'iilari:'eiiieiit  of  tin 


|ileen  to  ^i\c  ri:-e  to  iiii|)leasilit  eoiifiisii 


le    lar;^e    iiia|ont\'  of  ea>es    the 


e  are  jprcseiit   at    one  time 


-iiiirK'  or  in  >i 


nail  iiiiiii 


i)er,  t 


riiiii  "i  to  10  or 


1(1.    I 


11  villllir  elllMrell  tlie\- 


ale.    in    iii\    exiierieiiee,    ueiierallv    still    iewcr    than    in    adults.       In  tli 


latter  the  nuiiiher  i-  ajiaiii  diiiiiiiislied  in  ad 


vaneeil  aire, 


o  ileveloli  soliiew  Hal     more   allllll 


w 

hal 


itli  reirard  to 


sex.  the  exaiitlielll  a|)|ieal's  in  irelieral  t 
daiitly  in  women  than  in  men.  .\~  o|)|io--ed  to  some  oh-erveiv,  ;(>,  fnr 
iii-taiiee,  .MnrchiMiii,  I  would  di-tinetly  eiii|iha>i/e  thi'  tiu't  that  the 
ro-eola    iiiav    he   eiitil'eK-    waiitiiii;-   thr>ii|i.dioiit    the   entire   e<iiir>e   ot'  the 


Thus,    iif   iL'til    easo    (phserveil    at    the    lAMpsie    crniic-,    |>ersistelll    aiiseiiee 
<il'  the  niseohe  was  iihserveil  ill   2(in.      riiiloiiliteillv.  the  |ir(ifii>i(iii   and   the 


(K 


pmciit    of    the    exaiithcin   vary   at    dill   rent    limes    and    in    dillereiil 


In   tl 


1    the    vear    l.S.Hi 


I  ol 


iserved   m 


larL'er  imniher  of  eases   in   which   the   cxaiitl 


Hi 

iciii   was  seaiitv  than    iii   otiier 


iiiilmrir  a   rclativelv  iiiiieli 


Ot  Itlol  eases,  which  at  that  time  were  earefiillv  examined  from  t 


lis 


l«)int  of  view,  ini  niseohe  or  hut  isolaled  niies  were  found 


As. 


to  this  tlu'i'e  we 


'PI" 


re  |)erioc|s  ni  wliu 


h  the  rowohe  were  hut  rarelv  ahseiit,  and 


ihirli  their  averaLre  |irofusioii  was  especially  strikinir.      Perhaps   ll 


le  opmioii 


of  Hiiiie  ohservers,  that   the  roseola    is   to  he  considered   as 


ar  iiiilis|ieiisal)le 


leature  of  ty|ilioiil  fever,  may  have  liei'ii  formed  duriiiir  such  |M'rinds 

'I'liere  is  no  detiuite  relation  lietwecn  the  severity  (d'  the  disease  and 
the  den>ity  of  the  ro-eolons  erii]itioii,  altlioiicrh  I  think  I  have  ohserved 
eom|ilete  ahseiiee  more  \'\<  iieiitly  in  milder  or  aliortive  eas<'s  than  in 
-evere  and  loiij,^  protracted  eases.  The  eruption  is  tliereti>re  of  diajiiiostie 
and  not  of  proonosiie  siirniticance.  'i'lie  diinitioii  of  the  individual 
io-e->|)(it  i<  evidently  not  lon<:,  on  the  averaire  from  three  to  five  days. 
I  helieve  the  longest  period  may  he  jilaeed  at  from  seven  to  ten  davs. 
A  dunition  of  tiiiirteeii  days,  as  -tated  hy  Trousseau,  has  not  occiiitimI  in 
my  exp(  lieiiee.  It  is,  however,  a  characteristie  ii-atiire  of  the  roseola 
ot  typhoid  ti'ver  that,  while  the  old  spots  di.sap])ear,  iie\\  oiie>  are  eon- 
sfantiy  developing;,  so  that  eon-,  .|iiently  the  total  duration  cd'  the  eriip- 
titili  is  comparatively  loiifr.      1    should    place   the  aver:if;e  total  duration 


.m^m^wmmmmm^^' 


i^^^ 

%•«:':"- 


rvi-iioiii  I  i:\i:i! 


Ill  liic  cNMii'licni  MS  l)(t\V(iii  'wrKc  Mini  tiiiirtccii  (lays.  I  Iimvc  rardv 
iricoiinicrcil  a  lunger  diiraliiiii  tliaii  llinc  wnk-.  In  iiciicral  it  may  lie 
>t  ilicl  that  till'  niM'ola'  lat'cly  jicr-i-t  licyoiid  tlic  It  lirilc  stairc  of  tlic  (li>- 
iM-r.  .\ltliiiuij;|i  it  ralilHit  lir  denied  tiiat  iiuw  and  attain  i^nlated  fo-edlu' 
a|i|>eai'  diiriiiii  llie  al'eid'ile  stable,  one  ~iioiili|  lie  i  xtl'enielv  eritieal  in 
I'eu'ai'd    to    lliini. 

|)iii'iiiL;  rtenidoeeners  and  iTla|i-e~  the  ro-cola'  ;^en<'rally  fea|i|M'ar, 
ol'leii  ill  ei|iial  |ii-ot'ii-i(iii  ami  e\  en  in  i;ri  aler  deii-ily  llian  in  llie  |ii'iniarv 
allaek,  and  tlle\'  euntinile  -o  Inii^'  a~  tile  ll'Ver  |icr~i-!-.  I  niler  >lleli 
eireiini-tanee-  I'osi'iila'  IIKIV  lie  liilllld  ill  tin  tiiiirth  and  the  tittli  week  ot' 
the  (h~ea~e.  and  e\-en  later. 

I)ii  i-ri-e(i]a'  oeeiir  al-u  i'l  th<'  e(iill--e  i  if  i  itlier  disease.- '.'  I  lielii'VC 
elll(iri~eellee-  like  the  ty|ihiiid  fii-edke  (In  lull  rai'ely.  'llie  more  -killed 
and  the  iilole  e\|ielieneed  tln'  oli-er\er.  the  le-s  coimilonlv  will  he  feport 
iii-l.iiiees  ot'  ihi-  eharaeler.  <  )nl\  in  a  tiw  instances  ol'  aeiitc  niiliarv 
tiiliereiilo-is  and  ol' eei'elii'ci-|iinal  nieniiiLiilis,  which  were  shown  on  |io-l- 
inorlcin  exaininalion  not  to  lie  eoni|i!iealed  li\-  typhoid  l'e\er,  have  1 
oli-cr\'cd  n|iiiii  the  -kin  eni]ilions  iiidistiniiiii-hahle  Irom  tlu^  typhoid 
rn-enlie.  W  llile  in  ea-e-  of  the  aellte  eNaiitheiiiata,  as,  fill-  instaiiee, 
sniall-po\  and  typliii-  t'ever,  the  appearance  ot'  the  .-|iecitie  eruption  i- 
e'cnerally  preceded  I'nr  a  loiieer  or  slmrt  time  l>y  certain  evaiicscent 
exanlheni-,  I  lia\e  lint  rarely  ol>-erved  tliix'  as  foreninncrs  of  tli<' 
tvplioid  ro-e<ila.  (  )ril\'  in  a  fe\\  instances  in  wiimeii  and  children,  or  in 
delieatelv  liniit,  Monde,  liliie-evol  yoiiiie;  |)er.-oii-  have  I  ol)si'rV(Ml  evanes- 
cent, dilfii-e  or  piinctatv'  erythemas   n|Kin  the  trunk  and   the  extri'inities. 

it  is  notewiui'iv  tl  at  the  rose<ilii',  after  they  have  tiided,  jrciierally 
leave  no  tnicc;  nor  can  they  he  demonstratc<l  upon  the  dead  liody.  As 
the  -ole  tniec  rcmaiiiiiiL.'' diiriiiff  liti',  there  are  occasionally  ohserved  lii;lit- 
lirownish  or  vellowish  spots  of  hut  short  duration,  or,  more  fre(|nently, 
sliuht  liranny  de-(|iiamation  at  the  site  of  the  roseola'  and  in  their  immedi- 
ate vicinitv,  a  condition  that  appears  t< nr  especially  when  tlie  roseohe 

have  lieen  jirofiisc  and  have  persisteil  for  a  eonsidei-ahle  time.  I  have 
now  and  then  oliserv(Kl  in  children  and  yoiiiiir  adults  that  the  lenlicnlar 
et^oreseenee,  instead  of  siniplv  suhsidinj;  and  lailiiiL'",  i-  eonverte<l  at  its 
center  into  a  minute  conieal  vesicle,  whose  contents  soon  liecoiiu'  tnrliid 
and  nndeiiro  desie('ati<in.  'I'his  |)roeess  takes  place  in  the  sn|M'rfieial 
layer-   of  the  epidermis,  so   that    a    scar   is   never   left. 

it  i- a  iiotcwonhy  fiiet  that  the  roseohe  themselves,  re])re.si'ntiiifr,  as  we 
lia\c  -cell,  a  piirel\-  hypercniie  exanthcin,  practically  never  bwonie  liem- 
orrhaific  even  throii^.'-hout  the  course  of  their  further  existence.  I  heliex-e 
that  I  have  observed  this  in  Imt  a  few  cases  amonj;  thousands.      Only  in 


syMI'ToMS     IM)   (  iiMl'l.liATlDSS. 


127 


lliv  rxtliiiifly  iMif  cM--i>  111' Ijciiiunliaiiic  lyplidiii  t'cvci-.  >iicii  m-  ii;i\f  iiccii 
(|i-.iil)((l  (~|i(cially  In  Miinlii-oii  and  Li(lMriiiii~lt  r,  do  -><uw  ,,{'  ih,. 
niM'c.ho   liiciiiric   iiciii(iirlui::ic,  td^^ctlicr   with   (•xtvii>i.c   I)Ii>(mIv   >iitlii~iuii 

nt'  utiicr    |iirticiri-.   cit'  tliv   -kin  ficc  t'runi   ro-cila-.       Friiiii    llii~   < ditioii 

Miii-I  \.v  -hai-|>ly  ditli'ivntiatt'd  the  insi;r,,i(ic:iiii  Ik  iiKHTliams  int<>  the 
liair-fuljiilcs  ot'  tlic  li^^rs,  wiiicli  aic  not  at  all  rarely  (iKxrxtii  dm  iitj 
(■(iiivali-cciiri'  Iriiin  severe  attaek-  <if  ty|ili(iiil  t'e\ci-  in  a— (leiation  with 
the   dt\tln|inirnt    nt'  edetna    alxilit    tiie   aid<ie>. 

Kirciilly,  altc-nlioii  has  hern  direct. -.j  i,,  a  >lud\  »['  llu'  hiooil  ohlaiiied 
Irom  the  r(ise-s|«its,  not  alone  he<'aa.-e  nf  the  theoretic  -iiinitieanee,  Imt  alx) 
hecausc  (if  the  possihie  iliMirnosiie  value.  Neuhans  '  claims  to  have  tninid 
ihe  Hherlh  hacillns  in  mare  than  half  of  the  cases  exanjined  liv  hijii,  and 
m1-i  Kiniiiiycr  -  \va-  ei|nally  sneeessfid  in  1  case.  In  a  iar-e  nuuiher  of 
(iliscrvatiiins  directe.l  to  this  -xiint  I  have  ohtained  only  ne;.'ative  results,  as 
have  also  other  oh.servers,  as,  tlir  instance,  Fninkel  and  Sinunonds,  Seitz. 
.laiiowski,  ('hanleincs.se,  and  Widal. 

Since  the  ahove  was  written,  ty|>hoiddiacil|i  have  heen  ohtained  I'roni  the 
rosc-s|,ot.s  hy  Thieinich  ■  in  :!  out  of  7  eases  examined  ;  hv  Nenfeld,'  l;!  out 
ot  14  cases  ;  ( 'iirsehniann,'  14  out  of  L'K  c'a.ses  ;  Richardson,"  o  out  of  (i  eases  ■ 
Seiiol/,  and  Krause,'  14  out  of  Hi  ea.se.s.  The  method  n^<-d  in  most  of  these 
eases  consisted  in  ineisin;:  the  spot,  eolleetii,.'  a  dro|)  of  the  exuding'  hlood,  and 
inocnlatini;  thi.s,  loirether  with  .si>me  of  the  ti.ssue-serapinirs,  into  |li,i,|  media. 

!■;  Fninkel.-  I.y  excisnii:  the  spot.s,  phiein-  them  in  honillon,  and  so 
allouni-  the  haeterni  to  nndtiply  in  the  tissue,  Ikls  heen  ahle  to  demonstrate 
tlic  haciena  ni  sections.  From  all  of  this  work  it  seems  prohahle  that  a 
^■"ll«''' •'  the   hacteriii  in   the   hlood  of  the   rose-spots  alwavs  occurs. 

The  rosn.he  .d'  typhoid  fi'ver  are  alwdiitely  distinct  frmn  the  exaii- 
them  of  typhus  fev.r.  The  latter  is  made  npof  true  niaeiiles,  ami  not 
papules.  .\t  most  they  may  he  slij:litly  r:ii.s„l  fi„-  a  .short  time  iiiiine<li- 
Mtely  after  their  appearaiu'e.  In  fhrni  they  are  not  so  rejrular  as  the 
n-iohe,  and  their  horders  are  ditlii.se  aiul  iiidistinet.  I'urely  livi)Ofemie 
and  pale  red  at  first,  they  s<h)I1  heeoinr  heinoiTliajrie  from  the  center 
"iitward,  so  that  in  contradi.stincti.m  from  the  ty])li.,i(l  rostsda-  they  can 
"idy  in  p,irt  Ix"  made  to  disappear  on  pressure.  Their  color"  then 
hee..nies  cop|K.ry  red  or  dull  hhiish  ivd  .in.l  cv.  :>  di- ty  livid.  Ti.ey 
l<'ave  traces,  in  the  Ihrm  <d'  ^rnrni.sh-velh.w  or  l.roxvnish  siH)ts  (hlood- 
piiiinent),  far  into  convah'scence.  Tlie  exanthcm  of  tvphus  f,.vcr.  in 
ad.liti.m,  .appears,  on  the  .•iveniire.  son.cwh.it  earlier  than  the  tvphoid 
H'stsda-,  nam..|'-,  from  th..  third  to  tl...  lifth  day  of  the  dis.-a.^c.  I; 
never  apiM^ars   it,    crops,    hut    all    at    the   same   time,   s,.   that    in    from 

■  /(■/•/;■,.  /,/;„.   11-,,,./,,.   lK«i),   \,,.,  ,;,„|,|  44 

^  (•■„lr„lhl,,:   I,,,..,   .1,,,/.,    I.SK7,    N,,  ...  :  n,;,i.rh.  n.rd.    IC,,,-/,..    l.S!,.",. 

!  '^"'-  '•   "."■"•    "''•  ■''"■  =■  Mmtrh.  „u;l.   \V,.-h..  189(t    \„   48 

"  '''"'"■  ^^•■•'-  ■'■■'"■■■  1!^»<1.  vol.  X.  I  x,,t,  f.  /./,„,  .u,.,/.,  lid.  Ki 

^  X'-'t.f.  III,,).,  nd.  x.xxiv. 


128 


lYIIIoll'    I  IVI.I! 


I\\('lil\ -liiiir  !<•  tiiil\ -ciiilil  limir--.  nil  I  lie  :i\  i|-;ii:i.  I  lie  ci-|i|it  jnii  i-  iikiii  to 
li;i\  (■  alliiiliiil  il-  (Ictiiiili  ili\(lii|)iiiciit  ;iliil  (li-I  liliiitioii.  I  li:i\  i-  UcA  cf 
i.ll-ll\  ttl    ill   nillllicliiill    willl   lllr  (Aalllllllll   111'    l\|iliM-    t'cVir  llic   nri'udo- 

(Mnc(-  iIkiI  (•iiii-iiiiii<  ihc  nili  in  ca-c-  ..l'  i\|ili.ii(|  \'f\vv.  Tlic  ili-triliu- 
linli  III'  tlh'  cxanlliriii  I'f   |\  |i|iu-   ti\  cr    al-n    ilitli  r-    iiiariKi-l    ili-l  ilirl  ive 

mi: r  riniii    llial    nt'  I  \  |iliiiiil    \\-\<v.       Alllhiii^li    in    Imlli    llic    Iniiik    is 

iii\iil\i-(l  lir-I  ami  |iri  liialilv .  the  ciii|il  ion  o|'  Is'ilin-  Wwv  ixlcnd-  imt 
rarcU  tn  lln'  lair,  and  t-|Mriall\  to  tiic  cNti-ciiiilic-.  In  i'k'I.  it  i-  iillcii 
Mill  Ic—  diii-c  ii|>i>n  tli(-i-  llian  n|M  ii  lln'  iniiik.  and  il  i-  a  cliararlcri^lic 
lialniv,  lir-idr.-,  that  llic  cxaiilliciii.  in  markcil  culitfa-t  tn  tlii'  ili>triliu- 
timi  nl'  till'  l\|iliiiid  m^cdja'.  i-  iikclv  In  lir  r-]ic(ially  iiiarkc<l  n|iiiii  the 
tl.fi'aiMii-  and  tlic  diii--a  of  (lir  hand-,  uliilc  llin-r  |iai'i-  nf  the  (Atrcnii- 
tic-  iicai(-t  the  liin.k  afc  i:ot  iiiMiKn!  in  Micalrr,  !iiit  nllcii  rvtii  in 
I;'—,    di'i;fcr. 

i'rlirai'ia  and  |ia|iiilar  ixantlnni-  (( iric— inurr>  n  ay  !>(■  incntiniii'd  as 
I'aiilio  in  tlii'  cdnf-c  nt'  Ivpimid  t'cvcr.  1  h.iM-  nntcd  iiftiraiia  mily  in 
cxccptiiinal  iii<tancr>  at  llanilmru:,  and  in  tt..'!  per  I'lnt.  ot'  the  ca-i-  at 
l.(i|)-ir.      .Iinnir.  Ivaynimid.  LtMai^'-fc.  and  utlii  r-    rciMU't    the    |ii(-iiiif 

III' -cariatinitiinn  cri'iiti'iii-.  and  al-n  nt' a-ly  finptiun-.  wliirh  anpraird 

dilfinir  till-  -criinil  and  ai-n  ;'ii'  thiid  uirk.  ai'ii  uri'r  liy  iin  ini-an>  i\a- 
ni-fcnt.  .\|iart  tVniii  tlif  iiiiliai  \ai'ictii'-  '<\'  I'a-h  |)rrviiiii-ly  nn'iitiinud, 
1   ha\i'  iili-iT\rd  niithin;^-  nt'  thr  kind,  and   am  iniTiiird    tu  thi'  virw  that 

at   li'a-t  a  purti it'  tiir-r  rl'n]itiiiii-  air  In  hr  nm-idc  red    a>    dniL;-i'xan- 

tiuiiis,  and  this  semis  tlie  nmri'  jiruliaiilr.  a-  I'm-  a  Iniii:'  linii'  it  \v;i-  en.— 
toiiiarv  tn  treat  tvphnid  t'e\er  with  laijie  dn-ir.  nf  anti|)yietie  driii.^s, 
eanalile  nt'teii  nf  iiiihieinj.r  Varied  exantiieni-.  I'eeiiliur  i>liii.-ii,  livid 
splits.  varvin;.r  in  si/.e  t'mni  that  nl'  a  lentil  In  a  hali'-iiieh  in  diameter, 
have  been  de>erii)eil  liy  the  nlder  Freiieli  nli-ervei< — a  most  enMi](lete 
de-eri|itiiiii  has  Keen  i.n\en,  I'm-  iii>taiiee,  liy  Trnn^sean — a>  a  fre<|iieiit 
le-inll  lit"  the  -kill.  Thev  ha\e  lieeii  de>ii;liateil  t;"iehe>  lileiiatres  or  as 
tvphnid  pelinmata.  and  \Mre  eoiisidered  l>y  .Mnrehi-on  and  'rrons<ean  as 
alino>t  spei'itie  and  i>riiL'iiiisliealIy  favoralile  -iL^ii-  of  the  disease.  The 
famous  tv[)lii lid  |ieliiiinala  eanie  to  an  iiinoininioiir.  end  :  they  were  found 
to  lie  due  tn  Jiediellli. 

The  erii])tion  de-iiriiated  miliaria  crystallina  i-  worthy  of  nmre 
e;irefiil  eiiiisideratii ill.  It  oeeiir-  iiiiieh  nmre  t're(|Uently  in  .'ases  nt 
tvpimid    fever  than    in    tlmse  nf  other   infeetinils  di-eases. 

AlthiiiiLdi  I  eaniint  mltco  with  I-niiis,  \vlii>  was  ineliiu-il  to  attaeli 
SfK'eitie  siL'iiiliranii'  to  the  erii|itii>ii,  I  slioiilil  not  fail  to  iiieiilioii  that  of 
l.")()  sneeessive  eases  of  typhoid  fever  exauiiiieil  t'or  the  preseiiee  of  siiilaiii- 
ina.  these  were  found  in    iiiort  or  less    iiiarkecl  de^'ree   in   i'M.      With  retrunl 


.v)l//'/'/.t/s     IMi    (  n.vri.Kri  ln.\s. 


129 


to  the  ntliiT  iiifiMiiou.i  (liMii,-c.i.  I  iiimv  .-t:ii.'  ih.-ii  I   Imvf  oliscrvt-.I   crvsliilli 


iiiili.ina    |-;ir<ly  in   laMv-  of  tiir!i.-lc>  mihI   >r:irl<l    lever, 
ill  ca.^i^  lit    iiriilc  .-i'|plicciiiia  ;uiil  lyiiliii.s  tivci-. 


uikI    iiioi-f   tlfiiiiciilly 


ii|ilioii  of  miliaria  ;;ciiciallv  a|> 


till'    M\Cfa; 


:i\  l.itrr   III 


i-oiir^c  m|    i\- 


|ilioji|  H'vci-   tliaii    the  i-o.-coln. — fn, 111  il,,.  iiii,|,||,.  ,„•    tli. 


i|  of  ill,,  -cniiiil  to  tl ml  of  the  ihinl  ,,r  the  Ix 


lis.     Il  a|)|ii'ai-  ill  the  uijl-kiiouii  tiiriii  ot' loiin.li-li,  dj,! 
rviiii,'  in  ^i/o  from  tliat   of  tlio  luail   oi' 


:ilillili;;'  of  the  f  mrlli 


iiicl  \c-ii'li 


a  i>iii  to  that    of  a    lentil, 


if  vvliieli.    if   t||. 
•oaii'^ei'  to  f  ii'iii  Jal-' 


anil 


'ril|ilio|l     lie     Well     i|e\  elo|le(l,     two    or 

•111 


iiion-   j:eiiei-all\- 

ll'uer  etlliire>ee|iee>    of    ilTe- lllar  ei  illtoiir.        l'"ille(l   with 


rolileliN  ot'   water-like  el 

'I'll 


oarne->,   tlleV  euver  the  -kill    like  (Ir 


r 


iai:iiiali\e 'l'roii--eaii  and    l.oiii-    comiiaivd    tlieiii  with  tear-.      On 


aceoiiiit  .if  tlie  eiilorl 


ess  eoiitellts    and    the  e.\eeedilli;lv   tl 


tlie   ve-iele-.,  tlli'V  may  readilv   I VerlookMl   will 


111!     COVCI'IIIL;     of 


I  iiii|H'rfeei  illiimiiiati 


.Not    rarely  tliey  are  lii-t   a|i|.reei;it(.<l   on    |.al|iaiioii,  if  the   |ialiii   of  tl 


haiiil    1-    |ia-se,| 


iver   the   pails   oeeii] 


Heel     li\    tllelii. 


Tl 


ie\    cull    lie  -cell 


l-|leelallv      well      it       vi.'W 


iiilaiiiiiia  I  have  aiwav^  timiiii  livhlv  a.'id 


il     with    oliliijiie     liirht.        'i'he     eoiiteiit     of    tin 


line,      ft 
lire    of    1 


or   neutral,  ami    never  alka- 


never  l.eeomes  |iiiriilcnt,  am!  di-appears  by  alisorptioii  or  rnpt- 


le    Ve-iele-,     after     wliieh,     if     tliev 


Wfre    numerous,    lirannv 


«le-,|uaiiialioii   of  the   -kin    per-i-t.-   ti.r    a     tiw   .lavs.      Mill; 


irliest  and  ii 


1  un-eatesl  profusion  iip,>n  the  lower  portion  of  the  alidi 


iria    ;ipp(-.ir 


vieiidm^r  f,.,,ni  tlii,  -itualion  to  the  clie-t  and  the  lateral 


imeii, 


well   as   to   the   tlii.dis.      The  exaiifl 


jHirtions  ,,f  the 


the    f 


orearnis  am 


I    the    liMT-.       1     |,.|ve    oh-i 


hands  and   the  dorsa   of  the   iWt,   and 


■III    is  usually  scanty  ii|kii 
t    hut    rarely  ii|niii    tin 


n 

der  t 


crved    I 


never   U|xin   tlif  fai'c, 


irpetie  eruption-  aro  m  rare  in  ea-os  of  tyj.hoid  t^ver  that   I 
lis  eireiiiii-tanee  of  diafjrnostie    importanee    in    the  ditrereiit 


latum 


liom  other   iiiU'ctious  diseas 


ot  the  tre(|Ueiit  as-oeialioii  of  this  varietv  of 


\-ery  expeneiie(.<|    physician    is   aware 


lalaria,  eereliro-iiiiial  nieninL''itis, 


cnip.iion  with   pueiiinonia, 


intliien/a,  and   typliii-  fever.      Dnrinjr 


the  epid,  iiiie  of  typhus  t'evcr  at   IJiM-lill   ill    ISTIt   I  iili-crv.'d 


nirpe-  Ml  ..  |icr  cent,  of  all  cas 


herpes   in   ea- 


liir  instance, 
When  present  at  all,  I  li.ive  foiiiid 
•  ■s  -if  typhoid  fever  especi;il|y  iiiHiii  tile  face,  and  here  in  the 
ii-iial  situation-.  It  then  appeare<l  principally  in  the  first  w.rk,  at  tinus 
even  liellire  tli.^  appc.ii-aiiee  of  til,  -..-(.ilous  eruption,  and  far  less  c.im- 
inonly  at  a  lat.r  |H.riod.     In  c,-,ses  ot  .•onvale-cence  from  typhoid  fever  I 


vc  iiotiil    it   in   a    few  it 


in    the    form    of   intereo-tal    ami    femoi-.d    In 


istaiices  upon    the  trunk  .-ind   ll,e  e\t 


remities. 


•icrhardt   and  S'idel,  tl 


rpes.       The    ol 


iscfvatioii   .i( 


;i<iiilts,  I-  11, ,t   in  accord  will 


lat    lier[)e-  is   moi-,.  fre(|iient   in  children    than   ir 


my  own  cxperK-iKr. 


130 


TV  I'll' >l  1 1   I  IVIR. 


.53; 


I'll,'  .H.iirn'iKo  ..r   furuncles,   abscesses,    phlegmons,   iiii<! 

erysipelas  in  lln'  n.m-c  mC  i\|.||i.i.|  li\.i  i-  c|iiiic  -<rinii-.  While 
i)llli'^liiiiii»  :iii<l  cfN -i|)(l;i-  ;iri'  Ic--  ri.iiirnon  mikI  Io  lir  cMii-idi  icd  nitlicr 
a-  Miciilcrilal  niiiditi.. II-.  ..11.11  in  .•.iiinicti.in  with  -li^lil  ininrii-.  Im<1- 
S011-,  i'I<.,  t'liriimlr-  ;iiii|  -ni:ili  iiit;inc..ii-  ;ili-(i--.-  WW  III..!'!'  II. mini. n 
anil  I'l'  iin|)lr;i-:iiil  -i'/nili.'aii.r,  i-|.i'ri:ill\  iliiiiiiH  tin'  |  rii.il  uT  ildir- 
Vr-rrlirr  ami  .  .1' i' .11  \  ;ilr-iiliri'.  At'lrr  -lAii'i'  allink-'.!'  t_\|iiliiiil  t'lMT, 
<'i.n\  ali-iTlli-i'  ma\  lie  Lll'i'al  l\  |irc.|farlril  l.>  llii'lii.  1  iia\r  rVill  i.li-rr\i'il 
lit'r  llircalrnril  iliir.ll\  in  ililiililatnl  im  li  \  i.  Ilia  I-.  I  lia\r  tnrnnnlrrcil 
(■a-.~  in  uhi.-li  ri..iii  ilii  I..  M'  lait;ir  ..r  -malli  r  I'liniiu'li-  ami  al.-rr— rs 
(ii\ii.i|Mil  -111 .  r--ivcl\  ii|H.ii  liir  -kin  ami  had  |..  I.r  imi^il.  Tlir  nm-t 
I'll  i|iii'nt  -lal  ..I'  liirimciil..-i-  i-  ihi-  di.r-al  a-jH'l  "\'  tlic  trunk.  r-|iirially 
ihr  L;liilral  iVMi..ii.  'I'll.  II  llic  .lic-t  and  llir  alii|..imii.  lln  tlii^h-.  ami 
tlir  anil-  air  |iri't'.|-ai>l\  allaik.d.  l-'iirnm-iil.  .-i-  .  .f  tlii'  -kin  a|i|«'ar-  to 
ociiii-  \'ilh  r-|)c.ial  l'iii|nrm'\  at  linn-  wlini  ty|ilii.id  \\-\vv  i-  \  i.;l.|■l.ll-l\■ 
tl•<■al^d  u  il  li  tVr.|iiiiillv  |V|.i  .itrd  and  lA.ci  diliL'-iy  (■..Id  l.alli-.  .'-iillrr  I 
lia\  (■  al)ami..nc.l    tlii-  111.  tji..!!  ..t'  Irral  nirii!    t'lirniiciil.i-i-  ha-   l.ci'i.ni.'  Ir-^ 

(•(.iiiim.n   aiiiiiiiL'   ni>-   |iatii'nl-.      'I'.i  lir  -ri.ar.ilcil    iVmn  llii-  c Iili..n   arc 

till'  ali-co-t-  1.1'  till'  -kill  that  iiavc  htiii  i.li-t  rviil  a-  a>-i.<'iatcd  iiiani- 
ti-lali.iii-  III'  a  (■i.iniiii.'aliiiLr  |>\rnii,i.  with  -n|i|iiiratiiiii  i.l'  i..iiit-  ami 
pnrnlcnt  incta-ta^i-  in  intcniai  vi-rcra.  l'".iriiinati'iy,  tiic-c  iMTiincnccs 
ari'  raiT. 

Bed-sores,  wliiili  l'..rnii  riy  wrri'  ..m  ni'  tlir  nm-t  drcailcd  .•^('(|iiii< 
(.f  tvnhi.iil  t'cvcr,  have  licci.inr  an  iiiir..nim..n  niaiiit'r-tali..n  with  the 
(Irvcl.ijiiHciit  of  a  rational  iikhIc  ..f  ticatim'nt  ami  nl'  iiiir-ino-  i.f  the 
iiaticnt.  Kvm  in  -rvcif  ca-o  nf  kiiijr  diinitinii  they  lan  generally  he 
aviiidcd  111-  alM.rti'd  in  tlirir  early  -tajrc-.  Apart  i'min  cNccptiiiiial  comli- 
tiiiiis,  the  iM-ciirrcncc  of  a  1>(m1--oic  in  inivatt  prai'tirc.  as  ^v(•ll  a-  in  the 
hospital,    is  a    r(]iroa<li   to   tiic    pliy-iciaii   ami    \\w  attcmlaiits. 

In  the  ipiiUMiiii' I.f  typhoid  frvi  r  at  llaiiilnir};  in  l^Mi-^<7  I  ohscrvcd 
hcil-snr<>s  in  l.!t  p<T  icnl.,  and  in  Lcipsic  in  only  1  per  cvnt.  of  tiic  ('a.-is.  In 
coniirction  with  tlicsc  small  liL'nrcs  it  nmst  a.iditioimlly  he  taken  int..  coii- 
si.lcratioii  that  disproportioiiatfly  many  severe  cases,  often  in  a  iictrlcetcd 
state,  are  sent  lo  the  hospitals. 

The  scat  of  iircdilcctii.n  f..r  hcil-soivs  !-,  as  i-  well  known,  the  lower 
sacral  ami  the  irlnteal  nui  'ii  :  less  comnionly  tlii'  heels,  the  -capillar 
rotrion.  that  of  the  -piiioii-  pri.ce--e-  of  the  vertelira\  a-  well  a>  the 
o<'cii)ital  rcL'ion,  arc  involved.  ,\part  from  cMccdinyly  M>vcrc  ca.-cs 
f>{)nii>licatcd  liv  septic  or  other  eipially  irrave  conditions,  in  which  licd- 
.sores  may  ai)iM'ar  a-  carlv  a<  from  the  eii;lilli  to  thi'  fourteenth  <lay,  the 
atVccti.iii  is  a!wav>  a  late  inaiiifcstati f  the  disea.se.      It    |K'r>ist>  from 


.Sl.i//'/o.)/\  .i.v/.   ro.i//7./r.|/7o.V.V. 


V.il 


llir 


bitter  |Hirfi<.ii  of"  tlir   f;i)n'|.  «i:i 


i^'<'   iiiti>  the  [iciiiMl  (,(■ 


\' 


U  It  olt.ii  ,ijr.sj:rav:it.>,  .umpli,;,!,-,  „imI  |.n.lr,„  t-  .Mivni.lv. 
■  iiiuii-.  i;,iiii-  .,fl,..|-M,r.-  ,:,M  Im.  .Ii>iin^r|,i,|,„|_.,  ,;„.,  ,| 


.•IU1V:||.>.(.|1(C 


|>:irclltlitll<;illy    iviiiMikcl,    j,    |„,t     MiHiri, m 


>;it.  It   niav 


ii-i'rv.T>. 


.f  III. 


'I'l 


IC   -illl|>ll-t    ;ll|i| 


V    .•i|i|>r..iiil.-.l    l>\    Mill 


iiM'~l  i.iiiiiii.iii  i-  that    iii.liii'cil  I 


II-IImIK-  >..il..,|     l„„|v    II,, nil     ill..     I,..,|.        I,     ,r,.„,.,~,||v    |„ 


>\   |ir.>>iir.' 


simil     r.'^;i.iM     :iii.|    .>ii    ill,.    |||,„t 


K'"-   i'l    till 


lit'lii»«'    .ill  iiiii-..iilMc|    r.ili 


|>rcpiiiiii,.iu    jKiiiii.  1,1'   th,.    Mat 


l<— ,      with      III-      williiiiil      ,.,r|| 


.■\|iiiialiiiii  lit'  I 
l.l.nl-    iva.hl 


ic  ciiHLrnii^  I1.IIII-.  w  III 


.I.^Vli 


y   :iMi|    i~   alivadv  -.nurwliat    ili 


.•\|(.i-iir.'  iif  til. 


t-,    Willi 

"-<•■•.       'I'lii'ii 
'riiiiii,  uhii'li 


I"*    •'     '■•■<'     li (■   'I.MlaiV.llillll,    (nlliiur.!     \>\     Villi 

li-i.vMtii.ii  of  th..  all^tci!  |)art.  with  ih,.  luimaii 


'I.      .M.ain\1iilc   tlii 


liki'   -ImiioIi.  whiili,  aft 


.  i-li  ili-rii|iiraiiiiii 
111  111    a  liariliiiiiiit- 


•  Irl.irlinl    in     tlir.'ail- 
-Inllirl 


.■r  M  var\  111^-    liinr.  i^  lliiiiw  n  i.tl' 


or   1-    iviiiii\i..|    arlili.-ialK.       1- 


I,  wliiili    aNii    iiiav 


111'   <li-i'.i|iiri.<|,  >ii||. 


-Illirlllai 


I.HllH      |-|1|1|IC(||\|.       II--IU 


i\MI     111   ill.'    Illll- 


i^^-iii'LtIitIi'i 


ill  i-|iriially  N(.\-,.i'c  aiiil 

:iil\:iii.i-   iiiiir.'  an. I    iikh 

mihI.t;;!.  n.'.'1'ii-i,  aii.l  Mil,~.',|ii..|ii|y  l„.  .xlMiat,..!.  aiij  I   1 

iii-Iann-   uIi-.tv.'.!    ill.'   ~a.-nil   canal    tu 


|i.irli.'iil:iily  liii 


v   .i.'f|ii\    iii.un   III    il 


a-  :i   w  Imlc  nr  i^ 
MM    willi    ill.,    lii-t 
.iimI    >ni.ar\ ,  ih.'   >kiii   an.l 
I.'   may  lie   cxrulial.'.l. 
I  I'a-.-.  ill.'  i|.'~iriiiiiiiii 


'11 


II-    :iImi    iiiav 


lavc   III   -f\.'i-a 


IM'     IlIMIll'l 


Aiiiill 


i.r  vai'i.'ly  iif  |,„|-.,„.,..  wliiili,  | 


may  a[i|M'ai-  -imiiltaii.iiii^lv 

III  iniimi'ti.iii  with   .'.•ilivma  ami 

ill    'il.'  irliitcal   iin.i   .sicml 

ulrrl'.-  Ill'  iri'.'triij; 


ly  iva-.iii  (it'  it-  mil.!.'  nt' 


•  riLnii, 


III  M'M'i-al.  .'Vi'ii  in  I 


iiiiiH'i -  |>lai'(-,  .lev.  loll 


n'iiioii-. 


■mai.iii-  ami   fiinin.'nlon-   (.ni|ition> 
It    irivcs    i-i^.    ii,   „||,.|||  siijici-ticial 


ill.'  r.'~iill  lit'  want  ot' 


ii'iiiitlinc,  .'onHii.'ntat  various  ,„,int>,  ami  it  i>  ,.-jnriall> 


A  ;l, 


.•l.'JiiiliiK'v-  in   the  .are  of  tlie  pati. 


inl  vaii.'ty  I  w.nil.l  .iesiirnal.'  tl 


lit. 


the  Mlhenlaileoii-  h. 


Hot    alwav- 


re.iiiiil.ent  p.i>tiire,  lint  it 

all 


ill  pla.'o  that    are  most    Mllli(^•t(K| 


It  .Il 


t.)  proMire  in  ili. 


oe.'iirs  rather 


:iiiiy  liver  ilie   low-.Tiiio-t    |Mirti if  tl 

'liptli   of  tiie   aiiai    f.l.i.      I),.vel 


iw  the  <,Hiiteal  r.'frion,  pref.. 


le   -aeriitn  ami   the  . 


e-p.vial    severity,    this   varietv  .if  IknI- 


opinj-    almost    ex.'ln-iv.lv 


•oeeyx,  III    the 
ill    .a-.'-    of 


itNl— .ire   is    imlii'.itiN'e    ot' 


'■oii-tinitional  .li-Miri.an.'e  .,f  mitrition.      It    is  that  vari.'tv  tl 
iiiiavoiiial.le   ev.'ii    with    the   ,no<t 


priifi>iiii(I 
lat   mav  he 


piofiiiimily  stuporous    patients,  who  exhil 


criipiiloiis    .'are.      In    t| 


le   frener:illv 


'II  i-ioiialiy  a.'.piires   e.insi.l.i-ahl,.   e.xtent    without    tl 
Allien. l.uiN  heiii^r  attra.'te.!    to  it,  tl 


lit   11.1  maiiih-tatioii  of  pain,  it 


le  attention   of  tlie 
is  iH'eiirrintr  espc-ially  l,(van-e  at   the 


:iiiniiii:.  in  .spite  of  eonsi.lemhle   pr.iL're-sive  .l....p-s,...,t,..l   ,|,.. 


loll, 


^m  exhil, its   slisrht  or   no  al 


P 
teration.      When    I    hav 


V,   the    II 


pr.)eess    niore   eloselv,  a  (1 


-triietion, 
i>    lieeii  ahle   to 


'IV.',  mlilii'aii.,: 


ipiH'aretl   beneath  the  imaltere.1 


enso,  at    tini.'s    remarkalilv  iiis 


or  somewh.'it  rclilcmvl 


132 


7 1  rii<>ii<  1 1  \  I  u. 


i 


iil.iiialiMi-  -kill.      'I'll'-  -l.iii   i;iiii  nillv  llirii    l.r.-;iiiM    t;r;iilii,illy  ili-.i.lnnd 

|,lll|.|l      ,-,..|      Ml'     cAih      i:n.lll-ll      \rl|..\s      IVmMi     iliil.ihili r     111  tl|iii;l,.|,i|l. 

M,  iiliuliilc  llir  lliiliir;ili-.l  .in:i  'mm-  mihImv;..!!.-  -..Hiniii-  Ic,  tlir  iIim|,c 
111'  ili-lilKllv  .1.  in..ii-li'.ilili'  llii'lii;ilh.ii.  .\\A  ii"U  ili-i  Ii.iil;i  '•\  (litllnnil, 
[.iiliiil,  iliitv  |in-  i.ik.-  |il;i.c  li'.iM  ;i  iiihiiImi'  m|'  -mill  inv^uhiriy 
(li-iiilpiilol  (.|Minii:i-,  mill--  :iii  iiiri-iiiii  li;i-  Imri  |.ri  \  ii'ii-ly  iiiinlc. 
ll    i-  111. .-I   rli:iiarlrri-lii'  "I    llii-  variily  ut'  ln^l— mc  tli.il   I  lie  ili~triirrniii 

j,    t;||-    IV  i\lrli-l\i'    liripU    lliail    "miiil   I"'    -ll-lxrln  I   I'li'lii    llifiAlrlll 

i.fllir    |ial|ialilr  ililllliall v    liir  I  liinniii^    m   iii-ii.!niali f   llir-kiii. 

ir  i\Irii-i\r  iiiii-i"ii-  liavc  lni'ii  iiiacic,  nr  it  iIh'  lliiiiiir'i  -kin  lia-  Imiii 
|Mriiiillc<l  111  (Atiiliali-  -|ii.iilaiiiiiii-l\ ,  llir  iin  intir  •illnlai-  li--iii'  may  i.c 
ivmuviil  uilli  ilir  pn-  ill  lar^'c,  iVialili  ,  ili-i  ..Inn  il  -lirnl-.  ll  i-  «li  — 
till. MM-  i.f  tlii-  vaii.l\  rnrllicr  llial  lln'  .1.-1 1  inii\  i'  |irii.r— .  ImuiviT 
.•\lrii-i\.  it  mav  U'.  laivK  rslriuU  lirynml  llif  -iiliriilaiir. m- rumn'-tivf 
li--ii.'  int..  til.' ilr|itli.  ll-  main  iliiii-arlcri-lir  i-  Mil)ciit:ilifiiii>  iic<ri»is 
ami  -ii|i|inrali\r  -.  .tlriiiii'j  ..|'  tin-  rrlliilar  li— iif. 

Nalnrallv.  a  lii-liiirli'ih  i-  li.il   |>..-.-ilil.'  in  in:uliir  li.twc  n  ill.'  -cvcnil 
viiri.lii-  lit'  liril--i.r.  -  .l.-.i  ilnil    -mli  a-  lia.-  tmn    ma.i.'  liii     |iur|i.i-.-  ol 


('iiiii|ili'liii. --    ill  |ir.'-.iitalinn. 


(  Ml.  11  till' (litli'Vt'iit  varirlii-  aii'    inri'iiiil 


inlii  nil.'  aii.illii  r  ur  a|i|iiai'  -imnllaiiMin-ly  'ir  sin.  r--i\  civ  in  liii'  -aim' 
iii.liviiliial.  (  ir.'iiin-.'iiiitil  ;;aii^n'ii.'  .•!'  tlic  -Kin  in  "tliiT  >itiiati.iii-  llian 
till.-.'  thi'iatiiiril  ii\  linl— iiri-iir<iii'^\\itli<'\tri'inrnirity  anil  mily  in  unatly 
n.iiiri'il  iinJiviilual-,  ami  if  i-  lli.'ii  ut"  ..min.m-  -i-iiili.'an.'.'.  (  ).'.'iiriintr 
ll.  r.'  an. I  tlup'  cntiiilv  witli.iiil  dhvimis  caii-.',  it  a|i|n'ar>  at  .illicr  liini'> 
.111  iiai't>  .it'  tlii'  -kill  that  liav.'  li.'.'ii  Mil.j.i't.'.l  l.i  ac'i.li'iit.il  tnnimati-m  m- 
t.i  till'  I'trt'i'l-  .if  ni.'a-niv-  rmiiluyitl  tm-  lln'raiK'Htir  |iiir|i.i-i'-.  'I'liii-.  I 
liavc.ili-.Tv.'d  in  -iliiali.ni-  w  lirri' [irr\  i.ii.-;y  ..  ■  i  lar.l-ii.i-!'  r,  :,  ilry  ■  ii|«. 
nr-.iint'  .itlicr-'i-<'all»'il  rc-iiM'italin^^  aL^i'iit  liati  lifcii  a|i|ili.'(l  (■ii-.'imiM'nlM'd 
uaiiLTi'm-  .if  tlic  -kin  in  an  aic:i  oi'  (•.im-ii.in.liiii;  toiiii  ami  cxtiiil. 
Al-n,  in  -iliiatiiiii-  'hat  lia.l  li-i  ii  cNiiii-i'.l  for  an  .'Xc— i\  cly  Imi^  tun.'  In 
ll,..  ai'tiun.if  a  i.i.iilti..'  .n"  an  icc-lia^s  1  liavc  ••x.c  |.liiinally  nli-'Tviil  the 
.li'Viliiiimi'iit  ..f  .'iilan.'.iu-  L'^m^rcn. — iiatnrally  mil  inclmlin.:  acute  luirn-; 
iir  tV.r/ini:.  TIk'  ...'.'iirivn.'.'  .if  true  ii.inia  as  a  -.'.|iU'l  <if  tyiilmi'l  f.'V.T 
i-  -n  frcimntlv  imnti.im'<l  l.y  oarlior  writ.rs  that  I  am  iiu'liiiHl  t.. 
il.iulit    wh.'thcr    the  .liaLnm-is   of   that    c.n.litinn    was   always   .•.irr.'ct. 

Amiini.'  the  lartrc  iiiimliir  of  cases  that  hav mie  im.ler  my  .ili-ervatinn 

1  have  only  once   -ren    an   atVecti.in  in  a  cliihl    nn.ler  the  most  wreti'li-il 
conditions   that   eonld    he  e.in-i.l(M'e<l   as   noma. 

A  word  inav  he  a.lded  with  ivirird  to  chaii^'es  in  the  hair  and  the 
nails.  FalliiiL'  mit  of  the  hair  is  well  known  and  so  cinimoii  that 
-.•ar.'elv    anv    tviilioid   natient    is   wliollv   ('Xempt    therefrom.      It   oeeiirs 


■•^)Mri'niS     |\/)    (  iiMfl  /I    \  1 1"\> 


l;J3 


.1(1 

liii  iiiu 


alrno-r    .v.l„-ix,lx     >,,..,„    ,|„^    ,...,||..    I,-,    ,n,„Mi,mlv  tl,r    ImmhI.  «r:,,v.ly 

'•''■'■  "I ''"■  I'"'"-  '■'■    i"  ''"•  ■'^ill^''-       T"'.  .a--^  n|-  ..,„M|,I..|,.  Ml,,|,....i:;, 

h    I..--  al.-..lMr,K    ,,r  .,11    III,     l,.,ir.,r  tl„.  I,.„K.  tli.-.l     I     l,;,v,.  ,,|„..|.v„l' 
r—ival. -,•,.,„•,.  r,o,„    ,^|,|„,i,l    l,.\, ■,•„.,,.   |,,rlL:,„  urii.|u..  ,Mi.|  ||,.. 
l.-i.M,    UM-    vMivrU     nl:,l.-.|    t,,    l|„.    ,.ii:.ri,i,-,|    ,|i,,,,-r.       'I'l,,'    I,.,,    ,,f    |,;iir 

n-,i.,llv    l„..J.,~    .Inrin^'ll,..    L.M    „,.,,k    ..rtln-    .11-,:,-.,  .,,,.1    ,i„„..,    1;,, 

'"'"   '■•"'^•il'' ■  '•v.-.i    u|.   I,,    ||„.    tin,.-   «1„.|,    i|„.    |,ali..|ii-    1V-, 

''"''■  "■"■''  'l|'."i"M-.        -I'hr  lUlirMN  ..,.,   1,..    :,--,i,-,,|   „i,l ,„,,.,n,|iv,. 

'"■'"■'".^  '''•"  il"^  ^ill  L'r.Mlu:,IK  nrain  tlnir  |.,ir  uiil„,„t  Mitili.iMl  anl. 
•nucTillv.  tl,..  Ii.iii-  l„  „„  „.  |„.  ,,.|,l;„-,.|  i„  ,vrt:,ni  |,,-.rl-  uliil,.  i,  i-  ,,ill 
liilliiii:  mt  in  oil„r  -iluati..,,-,  ri„.  ,„u  hair  i-  :;,  n.Tally  .hicl.T,  U;uA.'V. 
an.l  I-  lii-l.rlr~~.  ||„„,  traii-vrr-..  -■.li,.,,  ii  i-oli.n  (mi-  -oi,,,.  .li-taiir... 
nnlv  ll,rMiiu||,,„t  ,|,  ,,,,i,,.  |,,,.,|,_  ,„„  ,,„„„|  |„„  ,.||j|„|,.__,,  ,.;,,, „„^ 
-IMIMV    lliat    i-    |irnl,aMy  a-vMial.Hl   «ii|,    ||,r  .iirlin,--   alirn.-I    , -taiillv 

|irc>rlll. 

Afi.r    |.rulra,i,..l    ,,.v,..v  alta.'k-   of  iypl,.,i,l    f.^,,,.   ,|„.    nail-   aiv   ,„,( 
ninlv  tl,i„.  lu-t.Tl,-,.  an.l  Irial.!,..    Onlv  in  ,,n..  iii-lanrr  |,a\ v  I  ,,I,mtv-,1 

''""'  ' ■  '•"•"l''''''l>  'i"-"^Mi  ,,tl(V,„„  il„.  Iin-.r.,  and  in  part  aUu  ln„„ 

''"■  '"-•-••""I  llM-...vu,n.,|  i, .fill..  .„-...,,(•  t,„a|  aln,„.,.ia  [.ivvion-lv 

'"""' ■''•       '•'"i>l"'-.  -lii^lit    .'lian::.-    in    ll„.    lin,:,  r-naiU,  tar    |r--   r,,ni- 

iMMnlv  in  tl„.  tu..-naiU.  arr  tr,.,,n.„tlv  nl,-,.rv...l  .-vrn  altrr  ,.,-.-  ,.f  tv,,l,„i.l 
t.v.rof  Mi.Ml.Tal.'  -cv.rily  in  y-mM-  |.rr>,ms  and  to  u  lii.h  \  Vo.r,.|  ' 
'■''l''l  .illrntiun  Mianyy.ar-  a;;,,.  Tl,,-,.  ..„n-i-t  in  iran-v,,-.'.  .^nnT- 
N-  ,i,'|.r,.-M„n.  an,!  un„,N,.-  in  th,.  lH„|y  „f  ,|,„  „.,i|.  ^i,;,.,,  ,„„.„^ 
in  llu.  Ma-,.  „f  n,„-t  |,r,,i;„M„l  ,|,.|,r,-H„n  ,,f  ,1„,  l,.„iiK.  n,,,,.;,;,,,,  „f 
^|ln.l.  .tH,l„.  l,K.al  ,.v|,r,-M„n.  I,  i.  i„t..r,.-,in..  t,.  ,,.;„.  that  l...|,in,l 
till-  ,i,.|.r,.-ion  „r  ;;r..,,v,.  il,,.,-,.  lr,-,|U,.ntlv  ,„...„r.  a  n„,n.  .,r  !,.-<ni,|,. 
w.'li-iik  ,M,-k,..,ln^  ,;a,i  ..|,.va:l  •:  ;•  tl„.  „ail,  wl,l,.|,  ,.vi,l..nllv  i-  ,|,„.  ,o 
'!'<•  nn,,r„viM.  .,IU.u  nnu^nally  in,.,va.H,l,  .n.tritivc.  ,...n,liti,;ns  ,lnrin:,^ 
,"M\ali-.,.ctu'('.  '^ 


fi 
if 

Si- 


COURSE   OF    THE  FEVER;    ESPEOAL    CONDITION  OF    THE   BODY 

TEMPERATURE. 

Til,.    alt,Tati,,n-    in    l.,„ly-t,.,„|„.nitnro  ,-,Mi-titnt,.    ,,no    «f   tho    l.c-t- 

-tM,|„.,|   ,.|,apt,.r.  ,.f  ty,,l,„i.|    f,-,-,,.      Sin,.,.  tl„.  .l,.t,.nninati„„   l.v  A\-„n- 

'l''l"li  "f    th,.  tyi,i,.al   ,.„niv,.  „f  ,h,.   t,'tn|>,.ratnn.-,.nrv,.,   U<  „l,s,'.rvati,m 

'";'"■'■""""""■"''''"•   ""'^'    ''•"[""•'■■II"   <lia.rn,Mi,.  an.l   pr,.i:n..sti,-  ai.Is. 

un,|..rli,  I,'-  ....n-lnM.-n-  aiv.  „n  tlw  wl„,|,.,  .fill  appli,.,!,!,..'     Tli,  v  mn- 

-ntni...!    tl„.   Martinir-p,>int   .,f   f„rtl„.r   ..xt,.nsiv..   inv,.-tifrati..ns  .'.n   tl... 

1'^'"   "I   In-   |)upii-  an,|   Mi,.,.,.s.„rs.  an.l  uill   nn,!.,nl)ti.l]y  ,..nstit.itc  the 

'  /)..<^-,/,,  .1,,./,,  ,-,  /;/;„_  _y,,/_    |j,j^  ^n     ^    :.,:[..;  ,.„a  ,-.,ii ;.,.. 


1^4 


rvriioin  ii:vi:i:. 


\y.\A~  )',,r  -nh-Cfiiicnt  stinlio  of  the  triirili-  ('(im-c  of  tyjilioid  fever. 
\\  ithoiil  (loiilit.  till-  leiii|iei-;iture-\ari:iliiiii-  in  I  Ih>  roiir-e  i>i' l\  pimid  f(\cr 
:nv  Im  lie  eiiii-i.leivil  a-  llie  e\ |iiv--i. HI  n|'  iiaelerial  iiiti i\ idit i. in  anil  llie 
n-nltini;  i:cneial  i-lianL:i-  in  ilie  ImmIv  ami  llie  \  i-eei'a,  in  eonneeiinii 
wilh  wliieli.  nalin-:ill\.  imliviilnal  ennililion-,  and  e-|)i'eially  the  |)li\ -i<'al 
-tale  iif  the  |ialient  hel^ie  the  allaek-.  afe  e(i-(i|ierative  in  the  liiUe-t 
(K'lZree.  \\  ilh  llle  ei  .nei  |lt  iull  (  .t'  tile  fe\  (T  a-  tile  e\|ire— inn  of  the 
-|ieeitie  ni.'iiiid  eoiidilion-  takin-  [ilao'  uithiii  the  l.od\  .  i  he  oh-ei'\a- 
tion  made  h\  Wunderli.'h  am!  hi-  |in|iil--.  thai  th(  \arion-  analoinie 
-ta'^e-  of  ilie  t\|ihoid  di-ea-e-|iroei--  are  re|ii'odiiei  d  in  a|i)iro\iniatel_v 
tvpieal  iii-e-  in  the  foi-in  ol'  the  eur\c.  i~  in  aeeord.  \\  inideilieh  even 
ad<le<l,  with  |ierl'e<-l  jii-l  iee.  thai.  e\  en  in  ea-e-  |iui'-niii;^  a  le--  reoiiJai' of 
a  eoni]ilieale<l  ei>ni--e.  eeHain  di-i;neti\e  tiaini'e-  of  llie  l\|iieal  eni'vo 
|ia--ed  thloii-h  the  I'elirile  eoin--e  like  a  rul  line.  The  -tatellient  ol 
Wiimieilieh.  thai  i;ii--reaeliinH'  diauuo-tie  eoiiehi-ioii-  ean  lie  funned 
from   iheeiMve   and  iVoni    certain   part- ot'  it.  i-   lia-ed  n|ion   ihe-e  taet.--. 

■file  seielililie  >IUiiv  of  llie  fe\  e|--eiirve    Il|ii<'(l  a   l:ir:;e    liuiiiher  nf  elin- 

ieiaii.*  durinLr  ^^unlle^liell'.- '  time  ami  liir  muui\  _veai>  aflei-wanl.  Amniit: 
Wllliilerlieh's  |i|i|iil>  vvlio  ilcr-er\e  eMieeial  ereiiil  in  t  Id-  eolilieeliiin,  'I'hier- 
feliler.-  I'lile.'  l-'ieiller.'  Waeli.-miith.    ami  ■flioma>'  >linui.|  he  mi'iitiened. 

.\ii  e\eeHeiit  Miiiiiiiary.  liai?ed  upnn  |ierMiiial  e\|.eri(  iiee.  has  l.een  made 
liv  (IriessiiiL'er.'  'I'lie  |Uililicali(iiis  nf  iliiumler.'  I  ,ie!u  rmei>lei-. '  .iiii-Leiiseii,'" 
/iiMii>.>iMi."  ami  Imimi-maiin  ''  eo|l^litut(■ll  fiirllier  a  mine  of  imiKirlanl  nli- 
.-ervatiiins    heariiiL'   iijion   ihe   fe\er  ot   ty|ihoiil. 

'I'he  a\'eraue  (hiiaiion  ol'  the  I'elirile  jieriod  in  a  moderately  -exere  oi- 
severe  ea-e  of  t\|ilioiil  fe\er  i-,  a-  ha-  lieell  mentioned,  fl'oin  three  III 
tlmr  week-.  ( ienerall\-.  the  M'hetnalie  n  |iiv-enlation  of  the  tein|ieratnre- 
eiirve  i-  lia-ed  n|ioii  a  duration  of  toiiv  Week-,  the  eharaeter  of  theiiirve 
liein- i-talili-heil  for  eaeh  individual  week.  It  a|i|iear-  lietlei-  to  nie  to 
di\  ide  the  (li-ea>e  into  ihiee  of  t'oilf  \K\n>.  and  ajiineeiate  fnnu  the  ollt.-et 

1  Wiin.lirli.li,  .1  A  1  iJ.,,.;.>l.  Il'ill.  H.l  ^^i  Is.".;.  :ni.l  l!.l.  ^^ii.l^•■.^. 
yir.-l,.  .1   II,  :n...   \\.\    iii  .    lse,l       /),     77,,--»/(.»,-7/-;rom  l^ranknihrtt..  'M  >  ,\  .   I.iip-ir. 

'  ,(/■.•/,.  I.  /,/,„.;. J^  i!,:ii  .  l!.l   \iv.  ■■  /'■'■'■  l'"l   ^^''i- 

•,l,w,.',/.  //.;//.  .  li.l  iii  '  "•'"'•  "'!■  i^- 

«  ''"./..   Mil,  v..  S.  :!:;!  u.  VJT.  '  /•'"■■  ••''• 

-  Ih;,/..,,-/,.   A,;-/,    t\  l.i:„.  Mr.l  .   li.l    iii. 

•>  c.llrrt..!  ir..,/.v.  ■■Ty|.li..iil  Fi'vrr"  in  7'V,„ «><■»■«  U,n,.ll„„-h.  l.iel«ni.ci.'^ttT 
nil.l  llaL'WlKll.ll.  n...l,„.-ht„wp;,  .n,.l  Vrr,,n-I„-  „l„-r  ,/;,■  .\,.„;  ,„/„„,,./.  s  halt,,,  \V„.sn-R 
fifi  th'hrrhnlirn   Kfnnkhritm,  Riislr.   1808. 

1"  A7;„, ■-•,■;,«■  .v^<,/,V»  uhn-  ,r,r  li,hn,i.lhi„n  'Ir^  .\/„/..,„: „„li „/./,iii  liiit  ki:lln,  Wussrr. 
ISsr,.      ■■  |)i,    l,i,'lu,-ivn  Knrni.Ti  di'^ 'lypliii-.       WJlmnui.' ^  S,niiii,lnhii  lilni.    V.:i-t,\ 

"  In  :i  iimiilier  ..f  -nKill.r  p<'i--in;il  |iii!.li.-nli"M-  iiml  -iiiiihir  |.ul.lii"in.in-  l.y  lii-- 
piij.il^. 

'■'  Zii.ni--..n    iinil    I  inniiriiKinn.  I/:.'  K„lt,i;issr,h.l„ni,ihn,:,,lr:,  Tiiph,,^  aMonunahx, 

IsTO, 


SYMl'Tu.\rs   AM)   (  iiMri.K  AIlD.y.S. 


i;m 


ti'i-f  ti-aiisitdi'v,  ill-(ittiiii'(|,  miiiI  v 


|irc-<iit.      I 


iiyiiiir  <li<tiirl)aii(cs  and  coiiiplaints  an 


If. 


II  ^'■<'iicnil,.tliis  stair,,   is  fnv  iVuni  tnir  frhrilf  iiia!iit'c.-tati( 


liiiwcvi  r,  cai-cfiil  iil)S('i-vatiiiii  he  tiiail 


.I'ly  if  tlic  t<'m|)ci-atiii-i'  (iC 


<■  111  tmirs  (iC  (•((idi'ini 


liai-tiru- 


.)•  1 1 


11'  |i:itifiit  lie  taken  ri'irnlarlv.  it' 


apparently  -till  healtliy  ipn^li-puMil  relative 


(■a~(s  are  nii: 


■eiv(^l  tliat  are  ailniitt(Kl 


int'i    tile    ho-pit:;]    (jiniiii:   tlie   peri.xl    of    ineiiliation    with   an    iixiel 


inite 


uia<:iin-i-^.  iir  it    nosceipinial    attacks    are    t 


i(iriiiiirl]|\    vtii(iie<l  fnmi    tl 


"Ul-it.  the  ediiiv,.  ,,(■  th,.   teinpei-atnre-eiifve  in    the    iieriod 


10 


\vill  ^l|ll\^■  in  iKit  a  few  tlial 
I 


inethiiiL"-    IS   takiiiir  place  wi 


III    inclibatiKll 
thin  the  liddv. 


11  a  <(Ttaiii  iiroporti.in  ,,t'  i|,c  .niiivi.hials  in  ,piestioi,  it  will  he  found 
ili:it  Willi,, II!  actual  fclirilc  elc  itioii  of  tcinp..nitnie.  a  mure  marKcd 
\ariatiun  in    tli..  daily  curve   tal-e<   place  than    under   physioldjric   eoiidi- 


136 


T)  rum II  i  i:vi:i: 


tiiiii- ;    llic  ti'iii|iri';itiii'>    wr.w   lie   >< ■liicw  lial    loucr  in    ilic   mnniin;^,  :inil  a 
\i\\   li'nili-  lit'  ;i  clci^rci-  lijiihci'    ill    the  ia fiiiiii:,  ih.in  uii-  nliMTvrd    in  tlic 


Kiticiit  w  lull'  111  a 


-tatc   ot'  licaltli.       Ill  <>tl 


|ialifiit>   a  t(iii|icraliirc 


IS     ( 


(ir  ~(iiiifu 


(■\('iiiiii:.   I  iihrr    -[Hiiiiai 


liat    liitilici-    i-  iM'ca-idiiaily  altaiiicd   tuwaiil    iiiiddav  nv 
r    \\\nvi-   tV('(|iii'iiliv    attiT    |ili\-ical   and 
t   t'i'diii  (iliitr  Iclirilc  di-ca-f-  \\\\<t 


1  n    ll|ii.-r  I'll] 


i\  al(-i'cii 


inciital  (Sri'tiiiii. 

cxliilpit   -iiliiiiinnal  triiipi  ralinc  in  ((in^iciucncc  nl'  cxliaii-tiini,  tlic  Imdv- 

triii|)cralurr   ri-c-   -unirulial,  tn   tlic   iKiniial    nt'  tlic    individual,   as   tiicv 


nirr   niHin  tlir   ^ta^c  nt'  niriiUatinn  nt'  the  altai 


lllldtT  sllcll 


itiiiu-  it    (sliiliit^  at    tiin 


111    ty|ilii.i(l   l(\fi-,  and 
(■>  iiiin-iiai   liiictiiatiiiii>  lictucni 


nKiniintr  ami  cvciuntr  (  V  i 


•)■ 


'l"lii>  in-Ial>ilit_v  lA'  tlic  tcin|icf;itiii('-ciir\  c  diirinc-  ilic  ]iciiiid  nt    iiicii- 
)ati(iii     i-  ijiiitc   Ljcnc rally  a.->i)riatc<l  with   cda-idiTalilc  varialiilitv  in  the 


iiil-c,  w  liirli  mi 


liu-lit    |)niviicali(in  iiicrca-c-  .-nddcniv  in  l'i'ci|iicnc\ ,  ar 


d 


j>articnlai'ly  in   the  cvmiiii;   i>  dt'tcii    nrirli  nmi-c  i-apid  tlian    it  i>  dniin 
licaltli. 


I    liclicvc  that   ^.Tcalcr   iiniiortinicc   than   is  cniiiiiionlv   L'ivon  shoiihl   he 


atlarhcd   1(1   the    |inlsf-lrni|ici'atiirc   ratio   iliiriiii:    the    |icriiMl   ot'    iiicilhati( 


il      nh 


m. 


■crvation    (it     tins 


ratid  at  tins  tunc  iiiav  ccca- 
sinnallv  lead  the  trained  oh- 
server  in  the  rit;ht  liireeticn. 
Invnrialiiv.  ami  aliimst  in  a 
ty|>ical  manner,  it  cei  iirs  re- 
|ieateilly  that  il\v<'liers  in  a 
hii.-|iital,  tnr  instance,  .-ervanl.s, 
laliiirers,  mechanics,  who  ex- 
hiliit  iiiilv  ij'enenil  sviii|iti)Tns 
and  a|i|iareiit!v  are  tree  t'nim 
t'ever.  are  sent  In  the  hiis|iital 
with  an  imietinite  iliaL'nnsi.s, 
and  snmctimes  with  a  siis|ii- 
eion  dl'  sininlatinn.  I'nder 
sni'h  circumstances  no  es|)ecial 
or^ranic  alleratinn  will  in  tact 
he  t'diind,  and  didv  on  carct'iil 
ohservatiiin  dt'  the  aliiiormally 
marked  tlnctiiatinn  in  the 
dailv  curve  and  tlie  inslahility 
df  the  ]iuli5e  will  atteutiim  he 
awakened  td  the  fact  that  ini- 
]x)rtant  proi  esses  are  takiie.''  place  in  the  hddy.  The  ex|(erieiiced  clinician 
will  then.  aiiinnL"-  dlher  thiiiL's.  think  dt'  the  iiKaihalidii-staL'e  of  lyiihoid 
lever,  and  recdmnieiid  rcr-t  in  hed  uiili  a  rotricted  diet.  <  >fteii  the  occnr- 
reiiec  df  rejieated  chilliness  at  the  licL'iiiniii'j-  df  the  fehrile  staire  and  the 
sulixijuent  characteristic  elevatidii  of  leniiieralure  w  ill  show  how  justilied 
wa>   the   caution   oh.-,  rveil   (  Fiir.    !•  i. 


l-"l'.  .1.  -Tniihir;!!  UK  (  iir\  •  li-.ilii  a  t  a-f  -  if  t\  [.h.  ,i.i 
fi'vcr  ill  a  uaitiT,  e.^'-iity  ^i\  vrar-^  ii!<i.  aHiiiiUi'l  w  ilh 
H  suspicion  t'f  Rimulatioii  Imrinj  tin-  Jirst  iiiiu' 'lay-^ 
ttiorr  WAS  Tin  fftirilt'  .'li'Viiti"n  "f  ti-iiUMTaliiri-.  tmt  mily 
Hljiu>riiiHlI\  wide  (tiiily  fliH'tUJUi'iii'*  On  ttu'  Icii'h  diiy 
111.-  fi'lirilr  |Mri.'.l  ..f  a  m.nl.Tat.'ly  s.^vin-  attai-k  of 
typlh-id   ft'\' T  piir^uiiii;  a   r- ^'ular  r.mr-r  si-t  in 


SiWtl'I'oMs  AMI   CDMriJCATfOXS. 


137 


Fli    the  til->t   \vc.-k    nf   fever    llie  elevation    nl'  t 


erii|iei-:iliire  a 
.1 


(leliliitive    lieiixlit    nf   the  felirile    pelicMl 

lii;;liel'.        I'lie  Ijiixle  (if  ascent  nf  the  tenipenituie-emve,  in  ecuil 


itaiii-   lh( 


in    j.n'iienU,   u|-    it    mav  ri- 


ti<in  fiMMi  that  (if  rnaiiv  (.ther  infeetidiis  d 


raili-tiMc- 


te\cr,  iineiiinoiiia,  and  varidia,  is  e(.ii,.faliv,  in  tl 
nmre  jjnnhial.       I  -iiallv,  t 
I'm-  from  tliree  to  live  <la\~ 


isease-,  a^,  for  instance,  typhiL 
le  case  (if  tvnhoid  tever 


le  a-ceri(hn^'  nidvenieiit  of  t 


le  curve  cdntiniie.' 


>nini(.nlv  the  entire  lir-t  w 


jiied  l>y  it.      This  niodc  (if  |ir(itiacte<l  ascent  is  in  it>elf 


eCK    IS   liecll- 


t'  ini|)(irtaiice  in 


ai-aeter- 
le  eiii-\c  in  detail    is  chanicteri>i  le.      Tlu 


ditfercniial  diajrndsis.       In  additi.m,    the  reniarhalily  iiiiifdrni,  el 

istic  e(iiir--e  (if  this  jmrtidn  >4'  t 

temperature   rises    in    such   a    maimer   that    it    i>   reirnlarlv  from  (Kl'^  t. 

1.0°  ('.  I 

exhiliits 


n;.dier  in   the  cveiim'r  than   (in  ll 


le    i>rece<lm;;-   evemnjr,  while  it 


.t    1 


•  ■acli  mdi-nmjr  a  rednctidii  of  from  (I.  I     td  n.i;    ('.,  sd  that 


It  ddc- 


iidt    liecmie  as    low   as    it    was  im    the    previdu,  day.      The    fdrm  df  tin 
a-((  nt    i-,  in    diher    werds,   step-like.       If,    in    this    wav,  en    the  evening 


'f  the  third    to  the  fifth  d; 


ly.  di-  in    markedly  pniti-aeted  cases   as  lati 


the  sixth  (ir  the   vcvcntli  day,  the  definitive   hei-dit  of  tl 


ivaehed  at  U)-  ('.  and  al 


ilidvc,  (Acn  n  ''(',  the  t'ever  tl 


le  tenipenitui'e  is 


fl.r 


a    week   or  e\ en    Idn^-cr,  nut    r.irciv 
■k~:4()M' 


If  a   w( 


len  remains  ( tinned 

t'k   and  a   iialf  (ir   two 


lidt  cxceediiiLr  the  pin- 


ind  alidvc  111  the  eveninu^  and  toward  morninj;  a  rednctidii 


In  i-dlated 


loloji'ie  \-ariatioii. 


in-taiices  >liir|iier  d..,ilv  var 


take  place  either  for  a  few  dav>  or  tl 


iatidiis    than  the    normal    mav 


irouirhoiit  the  entire  fchrile  stre 


that    thecdiir-eof  the    temperature  cldsely  ajipnixi, Mates  that   of 


le  -ell-c. 


tinned  fiver  in   the  tri 


111  severe  case-.    Stated  in  d 


This    feat 


lire  is  oliserved  almost   al 


wav^ 


clail 


vari.itions  onlvof  from  0.;!'^  to  0..')°(' 


"<Tiir,  or  even    le-,  l.dw.vn  the  hiehe-t 


evening'-  aiKl  the   moniiiiji-  ten; 


|"ialure,  and  at   time-  no  variation   at    all   is  ohserviHl 


Ii 


if     -iicli  e-iiceial  - 


'lly  higher.      It  i-  in  -ik^Ii 


peeial  -evcritv  the  averaire  t 


lor  sevcraf   (fays. 
ein|)eratnrc  al-o  is  ireiier- 


iiid    in  which,  il' 


-r-  that  the  tempenitiire  reaches  4  1  °  ( '.  and 


di-e:i-c,    ll 


le   -tap'    df    continued    fi 


liK'  palicnt  doe-  Udt    previously  siicciiinl)  td  th 
A'cr    may   lie   extended    to    two    wliol 


«eek-andc\en    nidre.      Ca-e-   -ettiiiLT    in  will 

^"•'ii'ii'''  :i    niore    favorahlc   a-pcct    after   the    lir-t  „,.ek    df  tl 


lev 


I  -licli    severitv  sdiiietini,.. 


le  Cdiitinned 


'I    III    Sd  tar    that    the    t( 


iiipcratiirc-cnrve    durintr    the    secdud    week 


'I'vlinc-  td  ,a  sonicwhat    lower  level,  althoiioh  die  slijrht  dejrree  of  v 
lion  |(er-i-ls  (  |'"iir.   ](i) 


ana- 


teverl 


That    peri(Kl  in  which  the  continued  fever  or  tl 


)ccoines  more  mat 


kcdl 


v  remittent  or 


■le-i-nalcd  the  third  feli 
<iiin-tance  that  tli. 


ic  feniittent  contimied 
■n  intermittent  i-  ;.r,.|||.r;dlv 


ll'  ptriod.    Thi-  first  manifc-ts  it-elf  l.v  tin 


I'liin^'-  tempciatnre-till  remain-  at  its  usual  lieiirht 


l:!S 


ryi'iinin  i  i:\i:i: 


(II     ;i|p|hm\ 


iiiiatrlv  sii,  wliili'  t!ic  iiicnimj:  I': 


iiimi-Inc'I,   t'niiii    l.-i 


t(i  'J    ( ".  iiiiil    iiiorc. 


oom-.-v,  MU'li  n'ini.->i<iii-  may  maUf  tluir  app 
(lie  or  tlu'  ciid  nt'  tlic  M'.'diiil  week,  wliilf    in  I 


ilnctiun  liccciiiiC'  iiu  'li  iii(ir(> 
ir  llic  (liM'a.-c  |iiir-ii'  a  iiiilil 
•aniiicc   a,~  carlv  a-  tlic  iiiid- 


lllllT    HKII 


kcl 


ca-o  llic  lii'iiimiHii:'    1 


if    thr 


t'diirtii 


-  (Icfcncd  to  llif    tliini  or  . 
I'k.      'I'Ir'    iliiiati f    thi-    1 


mill   in  -(  vciv 

ronMiirlircllU'Ilt 


Ml    ol    the    curve    is 


vanal)l(' ;     tioni     iliicf    to 
five     ila\^,     i-irclv     lonpr. 


1     is    i-|)c<ially    tin-    | 


>or- 


tion  I'i  tin  (iir\<'  iliat  i- 
iiio-t  i'rc<|iu'ntly  -liorti  ncd, 
ill  drlincd,  or  inoditicd. 
It  iiiav  (Vfii  riiiiaiii  wlioily 
uiidtvclopcd,  >o  liuit  till' 
.-ta^M'  of  d(-'cndin;.r  curve 
i'ollow-  directly  that  of 
contiiHied  fever  or  rciiiil- 
icnt   continuiHl   fevei'. 


T 


le    staiTc    o 


th 


-eelKlin 


fehrile       curve, 
liicli.    totretlier    witli    tlu 


jMX-ecHhiiir,  corre-iHiiKls  to 
the  anatomic  proeo-  of 
eleariiiiX     u\>     nf     the     last 


mtcstiiial     ulcers     aiu 


1      of 


ju'ojrre.— -ive 


•leatn/.ation, 


is  freliei-ally  ])laee<l  lie- 
t\ve<'ii  tlie  end  of  tlie 
third  and  the  middle  of 
the  fourth  week.  From 
five  to  ten  and  even  four- 
teen <lay^  tlien  elapse  lie- 
iiire  the  normal  is  reaeiied. 
In  this  stap'.  whii'h  i<  often 
ai>]>ropriately  de.-i^niated 
that  of  steep  eur\-os,  the  variation^  in  teinpeniture  are  often  more 
iiiaike.1  than  in  liie  previou>  sta^re.  so  that  persi-tently  or  for  <lays 
variati.ms  heiueeii  the  moniinjr  and  eveiiinjr  temix'nitiire-  may  he 
oli-erved,  such  a<  are  eiistoniarily  observed  in  the  eoui>e  of  di-eases 
presenting,-  a  true  intermilt.nt  tyi>e  of  fever.  Tempeniture-variations 
of  from   2°  to  -J..-)'  or  even   ;i°('.   are   un(h'r   nicli   cireumManees  not 


SYMrroMS  AM)  coMI'LllAlt'iys. 


i:w 


iiiifMiiiiiiiiii.      Tniulii'    lias    wiili    jinipiiciv    ]»(iintc<l    out    ilic    ~iiiii!:iiiiv 
liclwiTU    -iicli   curves   and   llio-f  nf  cci'taiii    tonus  o|'  [luluiouarv    tulxi- 


ilo-is,  anil   lia-  aci'onliiiicl 


V    -iKikcu   o|   a    licciic   -laiic 


In  >|ii'<'ial  caM'^  tlic  df-ccut  of  tlic  curve  takes  |ilacc  in  >ucli  a  nian- 
lli  !■  lliat  the  uiornin;::  aii<l  eveuiuLC  teiupei'alui'e-  of  tlie  I'ollowini^  (la\  are 
lower  lliau  tlio~eol'  the  |)ree(4lini:  (lay.  At  the  >aine  time  tlie  decline  iu 
tlie  nioiHiinj^  t(iu]ieratnre  at  the  liej.nnniu;^  ot'  the  ~tee|(  cur\cs  i>  <.renerallv 


V 


of  the  fehrile  >laire  may  not  rarely  lie  com|)re->ed    into  a  period  of  thr« 


n>iiiu<^ 

•  the  fel 

eel<s,    \v 

irve  a-  J 

reiimsta 

nai'ked    than    ll 


■i!;lil    ol'    the   evcniui:    ri-e.      In    milder  ease 


a   reirular  eour-e    it    mav  he   meulioued    that    the  enlii'i 


imeul    ol    the    tour   stai; 


the 


ith    the   eharaeteri-tie    de\clo| 

u-t  de-ci'ilied  tor  the -e\-ere  cases.       I  he  initial  -laijc  under  sueli 


la-l- 


about    i<iiu'  da\s  ;  the  succeedmsj;  |ierio<l  ot  cotitnuied 


ti'Ver  continues  until  the  end  of  tli<'  -econd  week,  thus  scarcelv  iuoin'  iIl 


■k  ;  while  the  -la^e  ot'  inl'  iinittent  and  dcel 


iiuui^-  cur\c  oceuiHc-  the 


~t  davsof  the  sei'ond  and  the  third  week 


>ueh  a  course  iua\   he  i 


In- 


ti'ated  by  the  diauianunalic  chart  of  Wnnderlich  i  I'ii:.   1  I  ). 
We   arc  iudelitiil  to  the  c\treniclv  eai'etul  and    paiu-t:ik 


em— en  and   Immeiiua 


tion^  ot'  Thomas,'  .liirLTenseli,- Zi 

~ucli    eoniiilete    kuowledu'c  ot'  the   conr<e  o|'  (he  t( 

typhoid  fever  that  thi-  ha~  hccoiiie  t'amiliar 


uis:  oh-erva- 
mn.'  and  other-  tor 


nipei'atnre    ui  ea-e-  ot' 


to  n-  h.iih  tor  cl:i\-  and  iiiLdit 


uid    from    hoin-  to   hour. 


Tl 


lere   is  iisuai:\-  an  imuilerr 


uii)e<l   ;isccndiu' 


le  eiirv<'  in  tli<>  eour- 


tcndeiiey  of  tl 

ot'tlie  afternoon,  ireiierallv  lietweeii  I 


if  tl 


c  ot   ine  (law 


that   in  the  late  liolir- 


1  tive  and  -cscii  o  cloc 


Iciiiiieratiire  is  likelv  to  1 


)(■  reached. 


1\,  the  maximum 
l''rom  thi-   jioint  oii,  into  the  iiitrht 
d   until   morning',  there  is  a  (rnidiial  decline,  so  that   the  icni])er;itiiiv 
lly   reaches  its  lowest    poi'it    hetweeii   six   and    nine  o'clock    in    the 


nsua 


iiiormnix. 


The  temperature-curve  often  exhihit-  a  noteworthy  deviation  in  i)er- 
soiis  who  hy  reason  of  their  oeeu|)ation  tr.nisfonn  wr\\t  into  dav.  Thus, 
I  have  ohserved,  es]i(>eially  in  liakcrs.  the  heiirht  of  the  tempenitiire  to 
occur  in  the  middle  of  the  nitrlit  or  eve.i  at  an  earlv  hour  of  nlo^ninL^ 
and  the  ({(H'liiie  in  the  curve  toward  the  eveiiiiif^.  The  ajred  and  children 
also  occasionally  exhihit  this  inverted  type  of  temperature. 

It  is  notowortiiy  also  that  for  days  and  even  for  weeks  mori^  than  one 
elevation  of  tempei-atnre  may  take  place  in  the  course  of  tweiity-fonr 
hours.      Xot   at   all   nirelv  there  are  two  stieh  elevations,  one  of  which 


'  A,:-/,.  ,/.    Ilrilk..    1W4. 

■•■  Kin,     \i,„i:,.,,    „/„■,■   ,/:.,    lirh.nmUu,,,,  ,)rs    A>: 
'il'^ir.    1S(')(). 


■finnltiiplmx    mii    Imltciii    Wnsi' 


J>ii  lirliandlu'ig  lies  Abiijininalfiipltii.t.  Lcip.-ic.  tsTO. 


1  in 


T)  rilnlh  ii.vi.n. 


"■iiicnillv  uciMii-   III  till'    inn 


liiiur  (if  till'  i-vciiiiii. 


Idli'  of   liir  (lav  .  \. 


ir    ii--  (■(! 


iniiiKiilv  at   M    ialc 


^\■  llulill;.^   till'    nii:lll.         Mnrr   lliall     tun   (■l(\:irHi|l>   I'f 

tciii|i('r:ilun-  in  llii'  IwciiIn -linir  hum-  a:c  li»  tVci|iicnt.  (  'iirv<'^  \Nitli  twn 
(ir  inure  -iicli  clrvMlion-  in  lliv  cniir-c  of'  tlic  ilay  may  -iiiiiftiini'~  pcr-i-t 
tlirnn<rlii>nt  tlic  ciilirr  ta-lii:iiiiii.  Tiny  arc  imt  .--pccially  nirt'  in  ca-i- 
in  wiiiili  tlir  ciirvc  in  trcncrai  txliiliit-  a  IfiiiU'iicy  I"  maikcil  i(ini--iiin- 
aiiil    intcruii— i"ii-    I  I'iir-    I"')-      ('uiii'tTiiiiiy   tlic   caii-c-   nl     ilic   niulli]il<' 


llnv  -f  III.'  ■! 


Fio    ll.-TempiTntiin'-i'iirvi-  from  .1  iniM  (■.!>.■  (.f  t>  lilu.i.l  fi  vcr  ol  rLBUlar  cour.v'  ,^ilt.r  Wander- 

llchV 


1 

)a\ 

Mt 

ii 

•  \ 

ISO 

T 

28 

IS 

30 

31 

32 

33|il 

35 

3C 

37 

38 

39 

^o•^^ 

<l3 

'la 

Vi 

ur^^ 

38 

-i 

•^ 

'-'-^ 

'T 

_- 

^^ 

^ 

T~ 

~T~ 

,1- 

•     'T 

— 

"" 

r-*- 

r*- 

"*  V 

Ut- 

___ 

_ 

37 

m 

•J 

1 

£ 

":3 

-~' 

~ 

— 

^ 

Z' 

— 

/ 

/ 

7 

T 
i 

H 

"■ 

^f  1  n 

1 

A 

^ 

ae 

r  Ml 

A 

"■  . 

t 

y.; 

/. 

/ 

.  w 

^\y 

-r' 

-^ 

r" 

,/i 

S^ 

'- 

^ 

_^ 

_. 

r 

1^ 

^ 

r 

y^ 

-J 

~\ 

s 

^- 

— 

^- 

~ 

-t     - 

^ 

- 

■V 

- 

btt 

^ 

__ 

^ 

5^ 

is^ 

3^ 

^^ 

.^^laL 

j_ 

..^ 

J 

Fic.    1-  -TiMriiK-riiliiri-iMirve  fn.m  11  ruM-  of  lyi.hoiil  fovur  in  n  prtviously  lu'iiUliy.  robust 
mMf],  nv.  Mty  tlirfe  y.ars  ul.l.    Severe  cum-  of  t.,  (.liui,!  fi-vtr  of   r.RUlur  i-nursi'.    sui-'u  of  >on- 

VHll'M'flK'Lr 

clivatiiiii-;  of  f('in|M'nitiirc  nutliinir  i>  known,  cspiKXilly  witli  rctrard  ti> 
tliiix'  that  |Hivi-t  rcLTiilarly  i'nr  a  cim^idcniMc  tiiiic.  As  a  tran-iinry 
jjhfiKiinciiiin  till'  inaiiiti'-latinii  i^  imt  at  all  imvly  raii-iil  liy  cMi'nial 
ili-tiiihaniT-,  in  part  hy  iiU'iitai  nr  phy.-iral  fxirtimi,  ami  in  part  al-u 
li\'  cniiiplii-.itiiin-. 

'['\w  -ta>ri'  iit'runvali-ri'ni'c,  likr  that  of  iiirtiliatiun,  ha-  liy  nu  mran- 
hivii  -ullliai'iitly  -tinlinl  with  ivjation  to  llir  -lati  nf  the  liiMly-ti'inprni- 
tnrr.      At    tlii-   tiiiir   al-o  the    nirvr  ixhihit-  a  typiral  •  har.utcr  in    I'ar 


syMrinMS   AM>   cnMri.K  A  lloys 


m 


iri'ciitfr  ili'irn'c  tliaii  in  iIm'  m^v  of  ilic  oiliir  uciiic  iiii'cciiuii~  ili>c;i-(-i. 
I'lii-  i-  (liiiil)tl»-~  due  to  tlic  iii'M'c  [initrariol  .liiraii'iii  ni  ilic  |iiciriliiijr 
tMii'ilc    >taj;f,    which    naturally    niu^t    rxcrt    a    cniiT-iiniiiliu^i    iiithiciiic 


all  x'MTc  ami 


iipiiii   tlic  turni  111'  the  iiirvi'  iii    the  afcluih'   >lai;r    anil  in 

[larticiilai'lv  Inn;,'-]'!'"'!'"''*'"'    '"a^t^   luay  cau-c  tiic   -taiif  nt' cnnvah-cciK 


tn  lit'  cliai-acti'i'i/cil  liy  cinacia 
The  tilNt  |)eliiMl  alter  i 
iloiiTliattKl  a^  the  -ta^'e  ot'  -111 
|mi'-ues  such  a  coui--e  that.  (Hi 
le>s  cuniinniilv  (in  lin'  next  sui 


t(i  .'1()°  ('.  (ir 


V 


I'dUl 


' 

' 

- 

iii' 

>n. 

il.'l 

ci\e~ 

eeuce 

in: 

>n( 

iiinai 

tcnij 

)ei-a 

It! 

ic  nil 

irniu;^-  f'ul 

d'eniiuL; 

:  .lay, 

e  on, 

,  the 

tin 

s  tini 

afti 

av  lie  iniKt  a|i|irii|)natelv 
tiirc.  Ill  detail,  the  eur\  e 
liiw  ini;  the  la-t  t'clnile  dav. 
■  ImkK  -telii|ieiature  declino 
rr  a  t'eltr'lc  -tatrc  iif   rather 


..evcre  iir  liiii^-|inilracted  eniir-e,  it  remains  alxait  ;>•)'"('.  or  emisideralily 
lieliiw,  ciintinuiiiLT  at  tinie>  up  to  une  and  a  halt'  ur  even  two  weeks,  and 
larelv  even   Ioiiltci-.      It'  the    |)atieiit  is  kept  at  re-t    |)hysically  and    iiieii- 

ion-  at   tlii-   time  pMiei-ally  reiiiai'i 
Tliev  are  then  -careelv 


tallv   and    in    licil,    the  ilailv    tliictiiat 


unusually  sliudit — sli^rhter  than  tl 
inoi'e  than  hall'  a  deirree.  ixcuelldlv 


teinpei-atiire  iisivs  little  altovi 
111'  convalescence,  the  da 


le  liln  -loloiric. 


()  that  111  the  eveiiniLr  the  liodv- 


{(j\  at  most  to  .'Jti..')    ('.    With  tl 


le  nroirre- 


ilv  tluetuatioiis  ill  the  temperati 


ire  lieconie  ~ome- 


wiiat  i^reatci,  appioxiinatiiiLT  the  |)hysioloixii',  and  thi'ii  the  temperature 
lieijilis  to  rise  aiTiiin.  until,  at  the  heiriniiiiiir  or  the  end  ol'  the  -ecmid 
week  of  the  at'clirile  sta;_'e,  iiirely  at  the  heirinniii^r  "•  the  third  week, 
it    has   re.iclied   the    le\  el  normal   to   the    individual  (  FIl'.  1-). 

Hoth  duriii;;  the  sta^rc  of  sulmoniial  teinpi'iiitiire,  as  well  as  durinsj 
the  sueeecHlinir  ])eriiMl,  the  course  of  the  tem|)eratiire  in  eoiivalescents,  how- 
ever iiuitiirm  it  appears  to  lie  durinir  rest,  mav  "xhiliit  marked  iii>taliility. 
All  ]xissilile  external  and  internal  iiifluenees — sliLdit  mental  cxeitenient, 
visits,  news,  hojics  and  disa])])ointments,  sli^rjit  dietetic  errors  or  transi- 
tory ■oiistipatniu — now  irenerally  <;ive  rise  to  sudden,  often  not  ineon- 
sideralile,  elevations  of  tem]H'r;iture.  Even  tliou^rh  the  temperature  do 
nut   rise  I'roni  the  suhuurmal   iniieh  ahove  the  itoriual.  the  elevation  is 


rtheless  attende<l  w  it!. 


ipt 


iiiitoins  comiiioi 


I   to  actual    felirile  stati 


Individuals  preseiitinij:  |)ersisteiit  siihnortnal  tenijierature  for  a  eoiwider 
alile  time  txhihit  fehrile  symptoms,  even  at  tem|M'r;ltiires  that  tlnriu; 
health   fall    within    the   limits   of  the   normal. 


The  stajre  of  <ulinormal   temiHTattire  in 


pri 


itnieteil  cases    ti 


minatiiisr  favoi-.ddv  is  as  sliariilv  and   con-taiitiv  marked  as  all  the  oth- 


staiies  o 


f  the  fell 


le  fehrile  ihtIoiI.      Wlicn   it  does  not   immiiliately  follow  the 
staire  of  stccj)  curves,  the  possibility  of  irreL'ularitios  must  be  thouuht  of, 

'  I    li:iM    ,.li»iT\ril  (';i-i'-   in  wliicli  tlir  t-'iiiprrMtu n'-riirvi'  ri'iiiiiini'd  ^uImuthkiI  fur 
!i>  It'nt^  a-  tiirt'i-  wi'i'k>  atul  t'vrn  litii^iT  at'trr  (li't'i'r\  i'>ot'iu-r. 


m-^ 


142 


TYi'iinii)  n  \i:n. 


anil   -ii<[Hri(in   ~lii.iilil   (-ixcially  uri-c  tli;it    trie   iiMrliid    pnM'c.-s   lias   not 
fiiiinly   -iili-iiliil.      A>  a    rule,   ri'iiiKlt-ciiici-  ur    rcla|i.~<'>  tlii'ii    M<'ciir. 

I  lioc  ari',  turtliiTinuic.  \<>  lie  cx- 
|icili'il  it'fiilarLli'iiii'iii  111'  tlic  .-ipIccii 


<|. 


iImc-  lint  (li-apiifar  uiili  rcilurlinii 
ill  llic  iMMly-lciiijiiratiirc.       Ii  u  ill 

lie  in,-lru<-ti\i'  at  tlic  (•i.iicjii-i (' 

llii~  MTlinii  Id  iv|ii-c.(iii(c  liair-<l,  - 
i;ialiiliialir;illy  tile  entire  Ieiii|Mia- 
tiiie-eiir\c',  Hut  alone  iii:it  uf  the 
initial  and  tlie  t'elnile  stau 


l>nt 


il.-c.  that  of  ll 


I' 


Au\ 


e  lielliMl  ot    llielllia- 


li"ii    aii<l    that    of 


eonvaleseeiiec 


(!■■ 


the 
the 


1). 


Duration  and   Form   of 
Individual  Sections  of 

Curve.  —  The   time    of  the 


tlr~i  ascent  of  the  temperature- 
curve  u-iially  oeeii|.ies.  a-  has 
lieeii    |ireviou-ly    nieiitioiieil,  ffiilii 


three  to  tiv( 


c  lallN,  les>  eoiiiinonlv  in  ai 


and  then  e-|)"- 
hilts.  it 


lna\'  take  loiiifer. 


here  also  («■■ 


eiif,  however,  cases   in  wliieli    tl 


•riod  of  ascent 


IS   shorter  ;   thus 


the   teniperatiire,  l'i>iii;r 
■h 


hv   stt 


may  reach  its  hei^dit  in  torty-eieht 
hoiii-s,  or  may  e\  eii  in  still  shorter 
time  ris(>  at  a  siiiude  jninp  to  the 
iMi.MiinillL''  of  thele\elof  tlieeon- 
liniied  fe\-er.  In  the  la'tef  I'Velit 
the  t'elirile  period  often  >ets  in  wiiii 
a  chill,  which  is  a  rare  occurrence 
in  ca<-es  atlendeil  w  itli  a  :-lo\v,  step- 
like ascent. 

The  old  rule  of'  \\'iindeilich, 
that  in  a  ea-e  of  typhoid  i'ever 
the  teiiipcratiii'c  atti  r  the  c<im- 
niellcemelil     of     the     :'>cent      I'.oes 

Hot    niarn    to  the  iKn-mal   e\-en   diiriiii.'-  the  niorniiiir  hours.   >till   ImhU 
L    (1(1    for    the    overwhelniiiiir   majority   of    all   casc~.        lint    rareU ,   and 


sy.\fl-lnM\  .\M)  (  iiMi-i,i(   \II0SS. 


11; 


ihrii   mnstly  ill  inihl  or  :ilMiiti\  .•  ca^c^,  ili,.  .-tcp-likc  M-cciit   of  tlic  t. 


|Mr;itiirr  i-   iiKxIilii'tl  l.y  :i  Iniii-itcprv  (Iccliiic   to   il 


II'   iiiiniia 


I   or  Im'I, 


lie    inorrilliir. 


KMcctliiiirly  nipid   a-rciil    ot'  llic   initial 


l«lillM|-;illirr 


'-^    cliroljii 


tcrcl 


far   more  t'rc.|ii.iitly  in    cliilihvn    than    in   a<liili~,  ami    in    the  liirin.  r   tl 
l:isli;riiiiii  an<l  tin'  -tap-  ot'  dct'crv  (-.riKc  al-u  arr  nf't 


(11  i.'l'cat  l\'  abridirci 


In  -(MK'ral — and  tin-  rctciv  t,,  .•JMldr.n  and  adiilt>  alike — a  rapid  a-c.nt 
ol'  tlic  tcin|(cratiirr  i-  |.c.niiar  ratlirr  to  tlic  iniMcr,  and  llicrcrorr  to  llic 
-111. ft 

l'"ar  u'l'cat.T  variability  witli  nlalion  to  tlic  dniatioii  and  llic  Corni  of 


(T  or  i'\cn  alporti\t 


lir  iiirvc  i-  rxliiliit.d   l.y  the   period  of   febrile  elevation  tlian   l.v  iji 


inilial  -U\irv. 


\\    Il 


ir  .■!ir\.'-  of  a  feu  c:;-!-,  niild   and 


■rww,  are  11 


.1. 


-ide,    riotl 


riotlniiLX    '.)'    a     t\|>iial    cliai-arter    \V(.idd 


_  la.ed 
>U^\.       If, 


II'   irnularitv    \mI 


lio\vr\rr.    iaiur  M'i'i.-   (.('   cjiai't-   aiv    -tiidii'd,    m.ii 

'II''  \>li"li'.  1 l.-iivni.       W  imdi'rlii'li  lia- di>liiii:iii<lii'd  two  Jai 

ol    i-a-.'-  d.'i.i'ndiiiir  ii]Min   tiir    dni-atioii   ..f   tlir   liri-lit    of    tl 
III     till'    til'-t     he    iiiclild.'-    -1 


U<'  L't'i'lljls 

II'    di-ca-i'. 


lort    raM'-   of  ihriT    wrt'k-'    d 


Mi'atioii    or   not 


niiirh    Ion 


tri'i',  Willi   a    fa-lii.diiin  of  ) 


I'olli    a    Uri 


k  I, 


.  a  wri'k    anil    a 


half 


""'  '"  'il'' ••' "1  II''   iiirjiid,-   |.rotrartMl   .'a-i-.  in  whirh    tlir   liistiirium 

la-t-  from  tliii'i'  to  -ix  wrrk-  and  rvni    loni.vr       I'.i'lwri'ii  tlii-i'  thciv  arc 


naliiralK-  all  po^iiilc  ^rrad; 


itioiw   and  variation-. 


Ic—  to  one  or  till'  otiicr  vai'ictv.      !•' 


a|i|)roMMiatiiiir   niorc  or 


iialiy,  there  i-  a  }:roii|i  of  atvpiea 


■a-c-    lo    lie  con-lilercd,    to   which    W'lindcrliih    atlachi'l 


far   too    littli 


iniportaiicc,  in  which   the  tcin|icralurc-ciirvi'  c\ 
cliarai'teri-tic.      '{'he  lir-t  of  W'liiidc 


liiiiit-  al.-..liitciv  noth 


ill 


's  irroiips  iiiilnde-  almost  soIcK 


inilil  ca-i'-  that   le^Milarly  terminate  in  recovery,  or  tho-c  that  ptiivnc  ai 


mifavoiiilijc  coiir-c  milv  in 
'tioii-  and  com|)lieation-,  -ml 


Tl 


le  -eeonil  ^jfroiip,  as  such 


.iisiH|iicnee  of  accidental    iin(ii\oral)le  eon- 
1  a-  intestinal  hcmoii'liai^c,  iiert'oi-atioii.  et<'. 
,  has  little  relation  to  the  ci.iirse  and  the  mode 
iioiip    iiiclmles    the    majority   of    the 


i.f   teriiniiation.      Althoiiirh    tl 

severe-       iscs,  it  comprises  al-o  many  of  moderate  scverit 

t'.   the   mildest. 


V,  e\  en  (low  II 


'file  total  (luratiim  of  the  fehrile  Mta'.'c,  concpniiiis:  wliich   a   fi 


tieal   .stateiiieut.s  may   he   niaile    hefiire   we   pass   ti 


I'W  stati: 


jiass  to  special  consideration  of 
variations  iii  its  course,  is  ci.nsiileral.ly  loiiircr  than  in  most  other  acute 
infedioiis  diseases.  For  adults  up  to  the  aire  of  lifly-tive  years  it  was  in 
more  than  half  of  iiiv  cases  .")()..")  jier  cent.)  not  iiiDre'thaii  twentv-iine  days, 
as.  however,  from  twenty-two  to  tliirtv-three  ilavs 
|ier  cent.  .,  while  iiiily  in  14  [kt  cent,  was  the  fehrile  statre  loiifrpr  tli.-ir 


1    not   a   tew    cases   it 


Jll.. 


Ill 


ilehilitated 


Tlie  last  ev 


eit  was  ol)! 


ierved  especially  in   the  a'.'e.l  ami  in  previously 


|H'rsoii.s.      The  ci.urs.'  of  the  fever  is  then    likelv  to  he  oscillati 


d    irreirular.        In    clii'dreii    the   fehrile    st 


Ainoui:   44:!  chililre 


lire   IS,  on   the    wliol 


e,   sliorlcr. 


n   up  to  tl'.e  ajre  of  fuurteeu   years,   in   whom    I    nind(= 


jv 


I II 


y )  /•//"//'  mil: 


I 


<ilwrviili..ii-    ii{.nn    ihi-  |i-iiil,    I    iMiiinl  ;i  iluiMli'.ii    ..f  luciil\  mmc  iImv-  nr    I, >s 
III    >>  .,    |„  I-    ,11,1,:     1. 1     l.iuviiti     |u.-iil\   luo    :ni.l     lliirl_\   lliiir    i1m\.-     hi     HI 

|„|-     rrlll      ;     nl      IIMirc     lIlMIl     I  ll  i  ll  \     I  ll  I<1'     A.W-     ill      7.1     | 'I   T     lllll. 

ll'  ill,.    ,,|.|,  I-  cliil'livii    -iri-    >(|i;u-Mli.l    iV hr    \  .p|iiiL.'rr.   ll    will    l,i-   >.tii 

,,i^tJ,i,lK     ll.^il     ill.-    t"riii.r    iiilliri-    :i|i|.r.i\niiaU      llir    l\|.r    "f    :l.lull^,      '1  li<- 
ihinilii'ii   "I    iIh'   lis  v\-    u  J,-  : 


1!,  I'A. .  ij  iw.  i.i'\-i\v..  ;iimI  lliiil\-ilir,-,-  ,lii>f 
Mi.if  lli:i[i  lliirn-llin  ■    'Im\- 


lli  .  hiMr,  ll  l.t  lui ,  11 
i-U\i-ll  ami  loiirliin 
yi'tti>  ol,l  lui-luHlVf 

1,11  11  |„.i-  ,  .  hi 

1  1    M 


111  ,  liiMnii  ii|>  I.I  llie 

IlL'C  "I    I.  II  M  111- 


■I  |i.  I    ,  ,  lit. 


i 


\\  illi  rc^iirii  111  llir  [in  iiliarilir-  in  iIh'  coiir-r  i>\  llic  IiAi  r,  lil  ii~  imw 

, Ju\iV  till'  -I'vnv  and  llic  -iv.n-l  c  a-« -.      I'.nlli  llm--.' of -Imri  ilnialii'ii 

;,,„!  tlm-c  iif  ri'  iimlractnl    ciiii-c  in   ailnll-  ii|i  In  llic    lliirtv -til'lli   or 

tlif    tlirtii'tli    vrai-   iif    lifr    Hviirralls    rxliiliil     a    cnii-iilrrMtilr   ili;:n I 

rlc\aliiin    ami    n.ii,\M.rth\-    rrt:iilarity   uf  llir    lrni|H  ralnrr.      'i'lic   ilitVcr- 
cnci'  lirlwiin  in.iniinL:-  ami   cviniiiL;    t(Mi|M  raliirf   i>   iimi'ially  n.il    iiioic 
tliali  unr  ilr',^|-ir.  iit'ttii  li--;  w  liilr  tlic  aviraur  iMurnini;  I'Vil   i-  liuiii  ■">!• 
,,,    ((I    C,  anil  tlic  cviiiiiii:  Icvtl  ii|)  til    |n.."i    < '.  ami  aiinvr.   Of  il-rlf  it   i- 

lit'  i.''r;ixi'  iiinrii    it     uilli   a    liii^li 
iMi,  i.r  th.  .h- iiM-  ii.|ii|irralnrr  lint  .-liiilit   niiiriiiiiLr 

rrnii--iiin-  taki-  plarr,  i-|irrially 
ir  tlir  triii|icratnrr  n main-  iiii- 
intlnrnrcil  in  -|iili'  nl'  tlir  irii- 
|ilii\  imnl  III"  riilil  lialli>  nr  utlitT 
anti|i\  rrlir  IrratnirnI  (  l-'ii:.  1  I ). 
!  I"  ihr  l(in|i«|-atnrr  lir  i-|iiiially 
liiuli,  ]iii>-ilili'  riini]iliratiiiii- 
>liiiiilil  lie  cant'iilly  Innkci]  liir. 
S(|itir  ciiialiliiin-,  |inrniiiiinia, 
ami  M'l'iind.arv  niciiiiii;iti.-  arc 
(-|iniallv  tu  1)1'  l<('|i;    in   niiiiil. 

..•,,.U-T,.,ii,H.r,it.i..-.un.   rii.tnaiii-i.rtv-                          \               ,^^,    ^^,^.^,^,^,  ^.^^|_,;_^_ 

pli,,i,l  I.Mr  in  ,,„.m..|ity  iM.i   >i.ir'' "1.1      111 

llviinlly   M-Mr..   I'.iiiri^.i    uillii.ilt    spiiiiil   .■.mil'liin  ,,,,,1    f;,\.,,,-   i,     intcri'll|)tf(l  l)V   11110 

tii.rs.     |i,.iitli.in  till   f.iurtiiiith  liiiv  .if  till.  .li>.  11-^1                                           ,       i     •  •'• 

III'  murr  iiiaikiil  intrnni>^i<iiis. 
Till'  trniiHratiUT  tlini  ilivlim-  -luMi'iily.  niuri'  livi|iirritly  iliirini:  th.'.lay 
than  ilnrin-  tlic  ni;:lit.  hIii'ii  liillini:  -rviTal  iIi'ltci's,  ami  mil  rarely 
fallinjr  <!ir  hilow  tin'  iiiinnal.  Markiil  .-iiiinltannui>  iliininiitiun  in 
till'  .-izc  III'  till'  iml-i'.  "illi  riiii-iikralili'  incna.^r  in  it-  Iniiiiciicy, 
staniix  tlii-  oiTiirn-mT  as  triir  .'iillaiiH'  (  Fiir.  •-'•".)•  I----  <'iiinnii.nly,  ami 
then    e-ixi-iallv    in     imliviiinal-    hetsveen    tlie  a-cs  <if   twenty-tive    and 


M   l//7'/l/s     l\/-    I  n\iri  K    \  ri<l.\S.  M.) 

lliii(\    vifli-^,  tiul   Ir--.  inarkiil  \  :iii:ii  lull-    in   llic  (■iirv(  -  .Hcur  irin|nii:ii-il\' 

vsilllolll    mIi\  iiill-   rail-.  ,    Inn    IIIIMlli  lliliil    \\  illi    Ir-lHilKliliL:   ■lilllillllli.ill    ill 

liii-iMii    ami    -i/r    nl'    ihr    |iiil-c    ami    willioiit    imna-r    in    il-    lic(|iirii(\  . 

Siirli    iii|rrrii|ii  i..ii  .  i.f  ilic   liii;li   ciiiiliiiiicil    ''<  vcr.  in    .iilnr    n-iicri-   a\~,, 

ii"l     a  I  t  I'  II  <l  I'  <l     \s  itii 

a larniiiiL''        -\  iii|ili'iii-, 

aini    \\  III.  Ii    ail'    ili'-i:;- 

iiiliil      |i-cml.i.-ii|la|i-c, 

!      Iiavc     iil)-i  i\  .il      ill 

-i\ .  I'al  ra-i-    ill    w  lii.'li       ;,    . 

lliiTc       WrVi'        \\\ii        i.r  ^-    ; 

llir.  .■    lisalMiii-    ilailv  ~   ■ 

(I'i-.     \'n.  ?'^ 

i'lir  i\|ilaiiaiiiiii  lit'  £   ; 

llii-     I'linarLalil.,     ami  ;   ■ 

lr..ni      ill.'      |i|-..|^ii.i-lic  V   Z 

-laiiil|i'iiiit        i^iiM  imIK  -.  i 

imiilli'iTni,    iii-cnircnrr  .   - 

\\  ill     l.iii'j'    rnnaiii    oli-  ?  r 

-.lire.  =    : 

1 II  ill.'  |iri'-<'iicc  ,,|'  =  ; 
~  II  <■  Il  |i-i'ml.M'.i|la|i-i',  =  ^ 
ll..\\c\TI',  llir  |i|-iiul|.i-  =  i 
-i-  ~liiiiilil  lir  i.r|iar(li'il  t  -^ 
it'  till'  -tau-c  .if  -i('i'|)  ;-  ^ 
.•iirvcs  iliii-.  nut  -iKiii  -  r 
tlirrcat'tcr  iicj^in  ..r  tlic  ^  ^ 
iiiliTiiii-siiiii-  ilii  nut  T  = 
a.'liially  make  tliiir  7  [' 
;i|i|ii  aram-c.  Sli.iiild,  1-^ 
"II  llir  r.iiitrarv,  tln'  L 
liiilv -ii'iii|)i'ratiirf  ri-ic  1  ':- 
■A'j.n\\\    (.1     it~     pi'.'viiiii-;  E 

li'M'l,    -n    til     (•iintiiuii'  - 

in    tlir     tiirni     ut'     the  ^ 

rarliiT      .■iiiitiniicil     or  - 

I'l'iiiittriit  itinni'il  tlirm,  tlic  liirtlu'i- cuiiisc  nt'  llic  ca-i'  nia\  lie  cNp.'i'tciI 

t.i  hr  ~rvirc.  1  have  tlii'ii  Milis<.<|iifntiy  ulc.'i'xcil  iriic  (•(illa|K<'.  diirinL'' 
\vliiili  ilcatli  iicciirrfil.  It'scviTc  cases  uf  lontr  dnratiuii  l«uin  tu  [Mirsiic 
.1  iii.irr  taviinilili'  (•(iitr-c,  tlic  liii;'li  rnntinucd  fi'xcr  is.  at  tlic  mil  ut'  the 
-ii'iiiiil  III-  the  iMiiiiiii'mTnii'iit  of  tiir  tliinl  week,  >rriii'|-all\- onnvirtcd  into 


.11 


i 


ic*" 


11« 


/I  rih'ih  1 1  vii: 


liiiiilti  ril   Ml-  cvrli  Mil    III 


|(  riiiilli  III    li  \  I  I    'V  illi  'II 


tV.  n  ii'-i  -  "f  IVmiii    I .' 


(   .  ;iiitl  iniilT  iM'lur.n   MMTiiiii-  :iii'l  '  \'  nm::  h  iii|"  i:ilin< 


-  (  I'l-.   liM. 


■IIIAl       1 1 1.  IS      Hull      !■ 


■  111111111     l"r   I  il:IiI 


\  -  unci  111. Ill  ,  (  ilhri-  «  illi   li  i^iil.ii  In 
III  i|    ii  iiii--iiiii-,    III' — iiii'l    till-    :i|||' 


ilU    h 


-I  \  lie    CM 


-I ila\  -  "I    l.i;:li 


iiiiiiii  il    |i  \i  r   Mllri'iiMlini;    «  itli   hIIh  r- 


il   r.  inllli  ill   iMiiliiiiii  il   II  A  1  r. 


niMiih  ,   111    ins    I  \\"  lull' 


1. 


Ill   i-  rli.ilMc'l'  ri/i  i|  li\   111'   1  IIIIIIII 


;I11IIIIIl;     1111- 


-l;|lli  I      IhMl     III''    lll'jil 


;i\i  ywj_v  t.  iiilii  iMliin 


||\       -llli-illi  -      W  lllli'lll       lll'li  M-l 


till       r.iiii--li.|i-     "I-     will 


I\      i-iihili 


l-icli  TmIiIi-    "ImiIx      (IllrlllMliiill-. 
'I'll 


--      I'l  'lllMliill       TM^i  - 


llnllMclrll 


.lll'-l        111      lilliilll 


111 


.1       -I'Srrc 
.1      lAllillit 

illi   t-|M  rial    tVi  i|iic'iir\    ;i    I'iriii    "I    I'  ni- 
si    w  illi    iiiMiiviil    II  iiii--i"n- 


111  l-allllc  -rill' 


ami    iiilrriiii--i'iii-. 


I 


\  I  n    «  lull    III    III! 


-t  ra-i-  tl  •■  la-Iiuiiini    '  \li 


liiliiliil  al   llir    lii'^iniiinu    tin     rliaracli  ri-- 


lil-     III'    M 


mrmiiiil    I.  \'  r,  Ini-  1"  ii'"l    i 


-.    likiK    I"  I"    niiirli  -li'Tti  r   Miiil 


III    til    I"'    niilar 


li 


li\    M  I"  ri' 


,|'  iiiarki  il  tliirtnali'iii-.       I  li'-'-  mn 


ik- 


lilv  intiiniitl.nl  iiirsi  -  a 
,:ir.  wliilr   i.l'l'  r   rliililivn    n|i 


IT  inii-t  ( iiii-lant   in  rliilili'  n  ii| 


nil  III  till    r|.  \i  nil 


III     tlu-     tiilllll  I  mil      N'MT     111 


iiT  jr.  Mill  ntl\' 


•Xllllllt     till'     i-.ill'll 


limi-   iili-rfMil    III    adults. 


'I'hr    llirm    nf  the    l.in]"  ratiiiT-iMirvr    i-  i( 


-  nlliti'    fi'liiMI-kalilr    ill    ^rvrri 


c    (.,..<,■  i; 


li    aliiivr.  a~    it     i- 


i-a>i—     111 


.Mi//'/"i/s    i\/'  <ii\irii(  i//'/.v.s. 


I  II  a  I -'I  Ml   Noilli^ir  :  11  III  It-  \\\\i<  li:i\  <    I iiir  i.M   iii'i  iiial  iil'i  I  \   <>|'  i|i  l<ill- 


lali 


>\     a   <li-'-il>ali  <l    Ml 


.1'   lit. 


"Iiiih-iii,  ..r  I  \liaii-liii;;  el  imiii' 
ili-ia-r.  I  iicli  i-  -iii'li  cii-ciiiii-ia'i.'i  -  iIk  |.in|pi  laliiii',  in  -pile  I  ilic 
111. .-I  -I  A  .r.' I  ..III--.-  ..r  ill.' ili~ia-.  .11.1  ill.'  III. .-I  alariiiiiii:  ;i.ii.  ral  ...ii.ji- 
li..ii.  I',  main-  ii..t  rar.  1\  ,  .  \  .  n  al  lli.  Ii.  iiiiil  ..I'  lli.  illa.k,  r.  niai'kal.U  l..\\ , 
-.llial  .iiiriiiL''  ill.'  lii.ii'iiiiiL;  li.iiir-  lli.'  I.  ni|i.  i  aim  •  -laii-.U  ri-i«  al".\.' 
.niial  ..r  r.  main-  ImI.ivs,  an. I  al  iiii;lil  .1...  -  ii.ii  .  M'.-iij  ,;|t     (  '.      'I'li.. 


til.'  n 


t..riii  ..I  ill.'  iiirv  .■  in  -n. 


I-  r.  niaiKalih    irr.Liiilar  :  iiiaik.'.l  r.  im 


-i..n-  alli'iai  III'  u  iili  u  i.l.',  .'.pJlaii-.'-lik.'  llniliiaiii.n-,  aii.l,  \\liili-  il.alli  i- 
iik.'lv  111  .ici'iii'  allim-l  al«a\-  in  \.i11iil;  |ialiilil-  \\liil.'  Iia\ill)j  I'X.i.ii- 
iiiL'ly  liiLrli    ti'in|>ii'alnr.',    iiimI.  r   lli.'    ciiciiin-lani'.'-    iii    (|U('-ti.iii    niai'k.'.j 


ll    ll.rlin.'   ..r    liinj 

iih 


\ -1    niii.i'aliii'.'    iiia\    lal 


111  \|i('l'lrnc.'. 


.ili-ci'vcr-  iiiav  rcaililv  Im'  il.ci  i\ 


.1  liy  ill.'  I.iw  I.  in|i.  i'aliii'.'-|.'\  .1  liiii'in;; 
llir  ciiiir-c  anil  liy  tlii'  tall  al  lli.'  ni.i-l  -.  rimi-  |i.  ri.Ml,  and  tiiil»  Ix; 
|.ni|ili'il    111   irivi'   a    tin  iifalili'    |>rii;^'iiii 


iii-i-   I  V's'Z.    I  7  ). 

ll'  iy|ili.iii!   li  \.i'  |iiii'-ui    ill.  ii'  I'.iiir-c 
"I'llily,  in  a  w.ik  ..r  .'nl\   a  1.  u   .Lr.-,  an.l  a.'c.n'.lin-K    uiili  a 
'ar.'.'ly    a|i|)r.'<-ialilr    l:i-li;:iiini  ;    Inn,  ..n    llir    hiIi.t    liaml,  ilii\    iiia\     lie 


'I'll.'  niilil  ami  tli.'  niil.|r-i 


at    tiiii.'-  -| 


IIIKJllI 


V  nn  iiiiiiLri'ii 


\\^ 


-liall  lali'i'  I'l  liirii 


1.1  111 


-.■paralc   I'.iii-i.l.  I'ali.ni 


.it' alHii'li\'i' aii.l    till'    iiii|i|.'-I    at.'liril. 


11.  :        .mlv    ill.'    Iliil.l 


la-t 


in;.''    il|)    I.i    till'.'.'  u. 
-.■.I     t'llIK'.         I'llr     III 


k-,  an.l    ill.'    |iriitrai'l.'.i    iiiil.l  ca-c-,  will    I..'  .Ii-- 
l.i    ca-.'-,    la-liiii.'    till'.'.'    w.'.k-,  ni.i-l     triiiiiintlv 


nlili'  111'  all  ill.'  I'.irm>  tlic  typical.       Willi  a  i'.  Iali\'.'lv  -Imrl  iliii'ali 


till'   in.livi.lnal   -taij:.'-  mi 


'(■   cliaracti'iM-licallv   iiiark.'.l    in    llii'  cIii'n  .'  (  l''i 


I  I.  p.   I-Jtl).      Ati.r   til.'   li.'i-lii    .if  ill.'    t; 


v.-r    lia-    lii'.'ii    I'.a.'li.'.l  williiii 


lu.i  an. 


I  liall',  at  till'  lat.'-t   tlnir,  .lav  -,  lli.'  .1 


iimli.iii  lit'  ill.'  ini.'  I'.miiim.'d 


t'.'v.r  i-  liki'ly  t.i  ll.'  iV.iiii  I'.iiir  ..r  liv.-  .I:i\-  t.ia  «.'.k.  Tli.'ii  iIht.' .K'ciir 
iii.ii'i'  niark.'il  tlii.'tiiati.ni-  nf  l.inprratnr.'  ..t'  l.."i  ('.,  an.l  tVcipii'iitlv 
iiiiicli  iii.ii-i',  at  lir~I  -till  with  ri-i'  nf  tli.'  .'Vi'iiiiiLr  t.'ni|>i'ratiir.'  t.i  tlial  .li" 
ill.'  iiiTc'ilin^r  .lay,  alter  wliicli,  at  tin'  i ml  ..f  tli.'  -(('.iii.l  ami  tli.'  lii.jiii- 
iiiiii.''  lit"  till'   third  week,  the  di'clin.'  K 


rill-  ill  till'  ti.rni  nt'  a   t 


rile   .-tc.'p 


Amithcr  i'xcc(.di!i;.''!y  i-nnini.ni    vnri.tv  i,f  inil.l  .'.iiir-.     i-   that  which 


tV.iiii  the  l)en;iiiiiiii:;  c.xhiliits   <rrcat  dailv  tl 


n.'tiiati.iiis  ill  the  tenipenitui- 


I'lirve,  with    I'.imiilete   ali-eiice  .if  trm-   .•untiliiled    (e\-('i',  .ir  with  an  iiidi 
cati.m  .if'  tlii-    f.ir  tw.i  dp  three  .lavs  at  im.-t.       I 


n    sdMie   I'a-e-  the  liiter- 


nii-.-i(iiis    exhihit    -iich    reiriilaritv    and    imit'.iriiiitv   as    In    tiiiic   a^   aiv 


iihservtMl 


111   (-a-cs  111'  true   intermittent   fever.      If,  under  such   circntn- 


-lanees,  the  reiiiainiii;:  sym|)l(iins   nf  typli.ii.l   fever   are   nut   sntHcicntlv 

well  marked,  ilitlicalty  and  ermr  in  diaLrn.i-i-  inav  .'ea.lilv  arise  ( i-'ii_r.  1,S). 

Espicially  the  markedly  interinittent  ami  r.niittent  caxs,  |)ai'tieiilarlv 


148 


ryriinin  ,i:\i:i:. 


tlio.-c  with  <'.iii~iilr|-:ilili'  iriT._r||l;ii'it\  in  llic  tiinii  of  liic  riii-\c  ;iiii|.iiii  tiic 
whole,  rniiilcratf  cifX  iilinii  dl'  tciii|iiia!inv.  arc  ai  liiiic-  i>\  iiiiii>nall\  Ioml: 
«luniti(Hi,  without  the  a|>iii>ai-:inc('  of  aii\  alanuiiii;  -yiiiiiioin-  ihioii-iioiit 
the  tiitirc  i-Miir-,..  |n  not  a  ttw ca-r-  witii  an  intc-rniitlcnt  i-iir\ctl' 
initial  -taLic  aUo  cvhiliil-  llii-  chai-actii-.  and  ivc-iMiiJc-crnrr-  ami  rcla|i-(- 
aiv  al-o  likcK  to  l>r  atlcndi'i!  with  cinally  niarkid  thictnation-  in  the 
ciii-vc.  Al-o,  cci-tain  ca-i-  ol'  anilinlator\  ty|ihoiil  t'cxci'  arc.  in  m; 
c\]iciiciicc.  atlcnih'il  uith  coii-idcfalilc  i-cnii--ion-  in  the  tein|icratni'c- 
cui'vc,  at  tinic-e\cii  with  -ncli  inai'ked  intenMi.--'on-  that  in  thi'  niofn- 
iiiL  or  late  in  the  cseninLTor  dnriiiLr  the  niiilit  (he  tcin|MratMi'e  i> 
-carceU  aKo\c  ihe  normal  level,  while  con-ideralilc  eje\ation-  lake  |ilac(' 
oiilv  (hiriiii:  the  midday  or   for   a    -liort    time  late    in    the    aflernoon.       I 


I'l.;.  1»-  -T.-mf..ratiir'' '  h;irl  |V,„ii  ii  niil.l  I'u-.- ..Ilyi.lr  ..'1  f.v.r  iii  a  .jirl.  .  siilil..  n  >iiir^  .1.1. 
Kn.ni  tlif  no  Mli.-tli  .Imv  ..f  th,'  .lisriis,'  111.'  .■..ur^.'  ..f  tlir  Ntlm-k  «  u>  al'i-l.ril.-.  'I  hr  <':rv  was 
111  irki-.llv  int.riaitt.iit  friii  as  .-arly  iis  Ih.'  sixth  .lay      'I  h.-  Kv.r  wtts  alinosl  [.urily  .1  .iimiiluin 


liavi'  in  a  iinnilicr  I'f  in-tance-  ol)-ervc<l  that  in  -iieh  ca-i-  thi'  diauiio-i< 
of  m.ilaria  wa<  m.-ide.  and  with  all  the  i:n"iti'i'  certainty  wjicn  tlic  eleva- 
tion of  tem|iei-atiire  wa-  initiated  with  a  chill.  Only  when  the  iiatieiit< 
went  to  l)e<l  and  ro-cola'.  -]ilenii  cnlaivcment,  and  ch:if:ieleri-tie  >t<iols 
a|i|iearcd  wa-  the  dia'jiio-i-  correct i'<i. 

In  ea-e- of  mild  tv|ilioid  f<'vcr  in  children  tlic  rcinitteiit  and  inter- 
luittcnt  form  of  llic  cm-vc  i-  n-nal.  Tniler  iich  circiim-tanie-  the 
teinpefatnre-curvc  i-  \cr\  rardy  retrnl.ar.  like  that  of  intermittent  te\er. 
On  the  conti-ny.  the  mo-t  marked  iriv.'nlarity  i-  the  rule.  I  mi-nally 
iiiarked  llnctuation-.  in  the  .Mirve.  alternating;  with  peri."!- of  lower  level 
!•[■  with  jieriods  of  ean-ele—  low  temperntiirc.  the  inverted  ty|K>with  low 
1  veninL;-  and  higher  morain:.'  teinjieratnrc,  often  c.niliine  with  a  Tmmlier 
ofoihei-   irrc^iilarili"-  to  make  .a  i|nite   rcinarkalilc  <-nr\  !■.       .\t    the  siinc 


S)MI'ri)MS   .\.\li   <  OMI'I.K  A  llo.WS. 


14!) 


tiliir.  liic  (•(iiiisc  ut"  such   cM-c-    i-   dftcti    pr.itnictcd,    >o   tliat    tlic   f'lhril 
iMii.d   in.iy  (■iiiitinilc  tnr  :i-   i]i:iiiy  :i-  -i\    of  cxcii    v'v^'.W     wci'k-,  iiiiil    tli 


if  ilif  iViiinU  and  llic  iil 


|iliy-i<  DIM  iiiav  he  -urch'  ti'i 


T 


HI    Miiii-li   attiiitiMii    (•aiiiii 


I    III'   jiaid    to  tl 


K'  intcniiiilc  lit  and    icniit- 


tcn;    I'cliril 


(•   i'iinr>c>   di-ciil)cd    and    li.    llic    i^rcal     irnuiilaiilii'>   i 


ll       >IICl 


<-ll|-V(-.       (  )iir    w 


liii    i~    iinlaniiliar    witli    ami    iiica|)al)lr    ut'    iiitcrpi'i'ti 


IlK'lll     is    i\ 


|Mi-id   I.I  liic    lialillily  (it    ;:rial 


•rmr    in    diaL/ini-i--  and    |ii'( 


r-|ii'cLiilv     III     -iicli    ca.-C'    Ihal     (TN  |iIiio(.|i,.||, 


><-|itlcciiiia, 


iiiliar\'    liilicri'iil 


and   iitlirr  di-ca-c-    tiir   nmi-c    t'carcd    than    t\|ih 


li'Vcr  arc  utlcii  incMrrcctl_\  (ha'^nn-cd.  It  ha-  ahvadv  liccn  imii'd  thai 
nut  ninch  i-  known  in  j.rciicnii  wiili  rcL^ai-d  lo  the  caii-c~  of  tlic  marked 
tinctnatioiis  in  tcinpcnitiirc.  The  condition-  are  dill'ercnt  «ith  rcH-.ird 
to  intliience-  tlial  teiiiiiomrily  exert  -neii  an  ctfect.  K-jiccialiv  in  c>- 
tihal   iicnioiTiiaL''c  and  e\ten-i\e  [icritoiiiti-  arc  to  lie  nicntioned  in    thi> 


•  •onnection 


eisi>tciit    (iiarrht 


a    al-o   i>  often   rcspoii-ihh'   fiir  iiiarkei 


renii~-ion>   ami    irreiriiiarities    m    tl 


'rraii-iciit    in:'-'kc<l    eii 


lion-  ot'  tcniuci-aliirc  w  itiioiit 


irnisc  -ijrnili<-aiice  niav  often  iic  attrihnted 


to   cxii-aiicoiir.    cxeitiiitr    intliicnce-,    mental 
liiudi    teiiipcratiii 


as    well    as    |)liysicak      'Idi 
pci-atiirc-    oli-crved    in    the    first    lioins    after    eiiti-ance    of    tii 


tiiex     arc  often    not 


|iatie:;t    into    tile    lio-|iitai    are    familiar,  and 

at;aiiic<l  tliroiiirl t  tlic  entire  attack.       Tlicy  arc    imdoiihtediy  iefcrai)i( 

to  llu  iji-tiirliaiice-.   axoeiated  willi  separation    from  one's  fiimiiv  and  ti 


the 


traiisiMirtatioii.      Xot  less  (iiniiliar  arc  t!ic  fchrilc  el 


of  typlinid    fever  alter  tlie  |)re>ciiec  ot'  \  i-it 
can-cd   iiy  prntraeicij  conversation,  excitiiiL' 


cvations    111  ease- 


ors,  as  well  as  those  that  arc 
iic\v>,  dietetic  error,  or  trct- 


tiiii:  oiit  of  lied  coiitrarv  to  instinct 


inns.      .Vatnrallv,  all  of  tl 


icsc  (K'cnr- 


>  are  periiii--ilile  in  explanation  of -nddi 


n 


oillv  when,  aft 


II  clexation  of  tcni])ci-atii 


er  iiio-t    thoroinrli  exaininarioii.  tlii-  eainiot    lie  attrilmtcKl 
to  s,,m,.    local   complication    or   to    Mi.'.dcii    e.xaccriiation   of  the   ..cnci-al 


m 


Variations  in  the  Curve  in  the  Stage  of  Defervescence. 


Ill  the  lar; 


:c  majority  ot    all    ca-es  of  typhoid    f,.ver,  tl 


le    severe   and  the 


denitcly  severe,  as  well   also  the    niild..r.  if  tiiev  liavc  in  the  preccd- 


iiiiT  -taij'o  ai) 


proaehed  the  tyiiie-a!  (linn  of  tl 


P 

le  curve,  the  transition  of  il 


leiiipenitnrc  to  normal  i-  likely  to  take  place  in     he  fimii  of  the  so-called 


-li<|i  eiir\e, 


'11 


n-  period    la-t-  tiir  from  tl 


ll'ce  to  eli;ht   oa\s  ill   ca-c 


moderate  and  not  too  proi meted  coin-e.      (^lite  irenci-allv,  aft 


er  >c\ere 


lell  a-  after  mild 


ca-c-.  the  curve   pa-s,.-  far  liclow   the  norma!  wiili  tli. 


la-t    marked    decline,  <(i  that  on  the  niorniiiij 

c\e,,llli.'-    the     lemperailtre    w  i 
peratlire    then   varies    in  ditrereiit 


lOllOW  111 


•S  the  first  afelirih 


lie     lietw  cell    '■)')  ^   ;in 


I  :;tr  ('.    Tl 


le    tilll- 


•a-es  :    it    iiiav — as    is   not    iiiiconiii" 


i:,() 


rvi'ii'iin  ri:vi:i:. 


^fSur}^'" 


and    lia-   Iktii   ili-'Tilin!  —  i-finain  -iil>ii..rm;n  wiv!    :iim1  Iniipr.  tlio 

~I:il:i'  mI'  t  iii;ici;ilinii  lliii-  t'nllnw  iii^i'  iiiili|.ili:ilr.',  Ir.;li''  ca-r-.  :itli  r 
ill,.  II,, rill      ha-  lin-u  ivarlic<l.  tlinv  tMlnw   men  >u     \td.  inv-ular 

lliirliiatioii-    ill    ill.'   cmxi.  lliroii^-li  u  hicli  tlir   p  ildi^ir  r\  cniiiL;-   Idii- 

|i,  ralinv  i-  ivaclicil  ami    |.rnlialil>   al-.,  i-  lAnclnl.      Afi' r  llii-   !ia-  i - 

tiinicl  fur  a  fru  .lay-  ami  I  lie  ili-ra-c  icml-  tnwarii  di  .  '''im'  Icriiiiiia- 
tiuii.  tlir  cliaraclci-i-lir  •{■.vj.r  lit'  ciiiaciatiiin  lici^iii^.  (  )iily  in  iln'  iiiilili  -t 
t'u-,-  .an  ncuvia  ■  and  ivliirn  cf  tin-  tcmiicraliirc-ciirvr  m  tlir  |ii.'>  •<liii,L^ 
i)li\ -iMlii-ic  t'.iriM  ami  lr\<l  tMlow  iniiiinlialilv.  witlicml  tlic  ncciirrcncf 
lit'  I  111'  -taui'  111'  rinai-iatiiiii. 

Till'   ra-i-   air    iml    raiv    in  wliirli   llir  licclinc  of  I('iii|icnitiir('  takes 
j)hau  mil  with  i^nvat  Ihictiiatinii-,  liul  -lailuallv.     This  uiiit'unii  dirliiic  is 

Dav  cjf  till  ilisiaai'. 


K,,;  19— TcnnHTimrpriiMvi,  «itli  uim-iuillv  in;irl-.  ,1  llii,timti.,ns  in  tho  t.niii.Ti.lur,  i-iirve 
1.  r.r.  tli-  primiirv  ,l,.f,Tv,-i  ,ni'0,  fr..in  m  , .-.-  -f  M-vr..-  Iyi.l...i.l  f.v.r.  .,f  ^-fnilly  iTntrMiU'il 
,-,,„rM.  iM.i«..rk..uin.M.v.  ....•.•ny,.ii>..l,i.     A  sli-ht  nrruil.sivmL.  bicm.  .■>.  tl.,- fnrtv  hrst  .lay 

..r  111.,  .h-.  .!-.■ 

likclv  to  111'  I'ciiniililid.  i.ii  tlic  av.T.ip'.  in  two  nr  tliivc  raivlv  imi|.  ,  days 
Still  aiiiitlur  \aiiriy  i>f  dil'rrx  (-.■.■mv  i-  that  in  whi.li,  after  niin-nally 
markcl  tliieliialinn-  in  the  eiirvr  [MT-i-tin.^-  fi.r  day-,  the  diil'eiviiee 
l.elweeii  iminnii-  and  ivi  niii-  tein|Hi-atiirr  liein;:  at  times  1  or  •> 
(h-ive-.  detliiite  ivdiieti.iii  111  teiiiperal life  take-  jilaee  within  Irmn 
IweKe  t.i  I  i-htein  liuiir-.  neea-ii iiKilly  within  a  -till  -Imrier  time,  ni  a 
-iii-lr  -n-..ki'.  In  ~neh  <'a-e-  I  liaxe  ,.li<erve<l  nvnide-eenee-  ami 
plap-e-  uiih    ;rinarkaMe    frii|iieney    (  Fi-.   I'-M.      At    time-   tlli^    variety 

,,f  -llddell  d.rline.if  I.  iM|.initlire  i-  |,reerdei|  I  ,y  iille  nr  Iwn  -Hell  marked 
tlilelualii.n-.  afler  the  eiirve  ha-  |.reviiill-ly  pre-erved  the  eharaeteri-lies 
,,f  a  ivmitt.nl  eoiitinned  fever.  I  iiikr -iieh  <aveuni-taiiee-  the  temper- 
atnre-tlnetiiatii.n-   are    mure  nfliii    initiated  and   aeeumpaiiied   hy   chills, 


s)  tin  <  IMS  .iMi  I  DM  ri. I'M  loss. 


10! 


This 


Mini    llii-    iiiMV  :il  time-  caii-c   ;:i-<-:iI    i  inliarra— inciil    iii   dwiirnosis 

iii;i\   ill'  traii-roriiicil    into  siti-l'iiii"ii  if  ii  - a|i|ii:ir-  lliat  tin-  i-  i.iily 


Dmv 

■  Uh'.W- 

^ 

2lL'L'ii21* 

i:5'J.i27]ail2<. 

;toi.ii|32l| 

^1 

:   ..    .1^1- 

^  _ 

__^ 

ij 

tH 

: 

:il: 

■ 

I  . 

J^\ 

1 

; 

z 

— 

I 

-^- 

^iJ 

-" 

-H 

__ 

~" 

38' 
137 

-\-^ 

-::.:H. 

lif-^ 

^ 

- 

■  1 

36 

*-  - 

U  : 

^^ 

.i„ 

'  T  19  20  21  ^2  2.1 

2't  25  2(i  27  28  20j 

'll    •     ■     ■     ' 

.   ;   .   ;'"..  "1 

''O^  J  ■  -i  ■ 

Jf//V 

r  :  ;  :':■:■ 

1 ;  •  i ;  J 

.    .    -  -^ 

|ri;:::J 

;(C.   -     ■     ■     -     - 

f^^A.^ 

^  :  '   ■   :!' 

•  tlL.Lxri-^ 

ll...  .",     Irnii.vr.iiur..  rliiirt  fn.iii  n-.'v,  n.  V:..  -l.-TcTiii..'..iiir,  <.|uirl  Ir.iiii  a  -  v^.re 

(.;[-.    ..I  i\  |.ii..iil  f.\i  r  111  !i  w  ..11  ru  I,  liiiil>  ^1  V  f-i>^-   'I  tyi.li..i.l  l.'\  .'r  in  ii  «..in;iii,  ihiilv  "rie 

y.^ir-..l.l-     Ii..f.rv,-.  .  u....   v\itli  t«i.  iniirki.l  y>  ar-    ..11      l-r..iM    ih.-  tHriily  r..iirtli    t..  the 

ilm  liiuti..ns  in  llii'i'iirv...  Willi  chills.  tw.  .ily-liflh  .|;iy  ..ft  ho  .li>,.  a-,.  tluT,-  ...•.iirr.-.l 

r.  .'ntii'iil  .h  .  liii...  "  illi.nit  aiit...-...l>'lit  n.arkt..l 
11.1.  tii.ui.'ii  Ml  Ihi-  .iirv... 


liav  of  thi'  .tis.'ase. 


a  iicciiii.'ir   fiiriii  of  rfiliictioii    in    tlic   curve,  ami    not   an    indication  ol   a 
coiniiiication  ( i'lir.  ■_'<>). 

It  i~  |ii-ol);ililv  Ica-t  frcc|ncnl  f^if  tlic  remittent  .■ontiiincil  fever  of  the 
tii-liLnntn  to  terniinate  siid.leiily.  with  a 
critii'al  decline,  at  a  single  -troke,  or 
(i.r  the  eri-e-  to  Im'  |ircccded  only  liy  a 
|ireeritieal  elevation  on  the  iireeedinir 
e\'eiiinir.  I  have  oli-erved  ihi-  variety 
of  dett'vvc-cence  more  fi'e(|nently  in 
vounj:-  ]iersciiis,  and  ojiecially  in  ejiil- 
di'iii.  liiit  it  occur-  al-o  now  ami  then 
ill   a. hilt-  (Imu-.-.    -Jl    and    -JlJ). 

l'"inallv.  ill  till'  le--  common  ca-e-  ot' 
tv|ilioid  t'evcr  that  |iiir-nc  an  irrcLrular 
ami  |irotracted  coiir-e  or  are  attemlcil 
with  r.'laiixelv  low   temperature   in   the 


-  I .  Ill]',  riilin.-  .-hiin    !Y..lii    a 
I..;  .!   ;.tT;H.k  ..f  l\  I'll. .1.1  f.\.  r  in  ii  man. 


|>re<eiice    ot'    -cverc     treileral     maniti'.-la-       im,  ..ly  tlv.  y.ar-  ..l.l     eriii..il   .l...'iii.. 


tion.-,     often     no     marhed      transitional 


■  f  It  .    I.inp.'ratnrt.  with    il..f.  r\ .  >...|m'. 
lift,  r  jiri'iriticul  ..|i.\  ali..n. 


^lai^'c   ill  the  ciir\e  can    l>e  noted,      'llii- 

sta^^c  then     jiur-iii-    an    irriu^nlar    coiir-c,   with    mor.-    ..r   le--    marked 

Ihietualioii-,    the    inornin^r  :iiiil    evening'    tcmpci-titiire-    hecoimn^r    irrad- 


i  i 


152 


rvi'ii'iin  I  i.vi-.n 


iialK  Iciu.r,  iiiiii  llic  ii.inii.il  I.  iiii»  niturc  i-  >lii\\!\  rcMrhtil.  Xi.w'd 
;nialMiiiii'all\,  tli(-c  :ir.'  |Mrlia|i-  ca-c-  u  illi  -Inw  ly  licaliiii:-  iili'i  i-.  "il!i 
nrnidi-ciic.-  an. I  -liij:';i-li  Ir-ioii-.  Tlir-c  aiv  tlir  caM'-  al-o  in  ulii.li 
loi-  a  Iniii;-  linir  iloiil.t  (xi-N,  and  crrtainly  Mia_\  lie  wanlinir  at  time  -  rv.n 
ailn-  thr  end  of  ilic  di-.a-c.  a-  t(i  wlial  \k\\\-  nl'  tlw  cnrxr  ImLmii;  Io  iIh' 
aclnal  Ivplmid  |)niii—  and  wliat  to  pu— ililr  cutnpliiatiun-  and  -.iiiul^. 
TIk'  alti'i-atii.n-  in  the  t^nii  ol'  the  cnrvf  in  n.iini'ctinn  with  drtiiiitc 
iniMlc-   of   ciiiirM    of    llio    t\|>iioi<l    atlark.    and    uitli    ini])orlaMl    -r.incis 

and  1- plication^,  will    I"'  more   aiiproprialcly  di-cn-M'd   in   the   i(-i>i'c- 

tivc  iliaptci's. 


CHANGES  IN  THE  CIRCULATORY  ORGANS. 

Tlic  di-cn«-ion  of  lin-c  will  U-  taki  n  n|)  In  n'  on  acconnt  of  tlif 
intimate  fciation  of  tin-  licart  and  tlir  jinl^'  to  the  frvi  r,  ami  « -pccially 
to  the  ^tat.■  of  liic  l><Hly-t(in|)iratiiic.  It  i-  well,  ll>r  rca.-oiis  tliat  wdl 
later  l.e  more  fnlly  detailed,  to  M'lnii-ate  in  the  de-eription  ("1h>  witlioiit 
especial  eai-diae  di-onlei>  and   tho^e  with  >evefe  Ik  ai't-atVeetioiis. 

We  -hall    he-in  with    a  <'oM-i«lel-ation  of  the  ehaiaeter  of  the  pulse 

in   ea-e-  pnr>ninir  an   nnc pji.'ated  eonfM'.      In  all  -tairo  of  sneli  ea-es 

a  eloM'  e..ir(-i)oiidenee  e\i^t^    hetween  tiie  llirm  of  the    pidM -cnrve   and 
the  >tate  of  the  teinpeiainfc. 

Ill  the  initial  >tajri'  it  will  he  ohserved  in  the  majority  of  l•a^es  that 
the  in.-iva>e  in  tlu'  fr..|neney  of  the  pnl.-e  take-  place  in  the  -ame  >te]v- 
like  manner  a>  the  a-<'ent  of  the  tempefatniv-enrve.  In  .-on>e  eaMS  the 
form  of  the  ))nl-e-enrve  imitate- exactly  that  ol'  the  tempei-atiii-c-eiirve. 
In  other  in^tan.'c-  the  pnl-e-fre(|nen<'y  ri-o  relatively  more  ^lowly; 
while  in  irritahle  in.lividnal>.  on  the  e<intrary,  it  reaches-  it^  hijrhe-t 
avera^'c  level  mor<'  ipiiekly  than  the  leinperalnre-cnrve.  per-i>tini:  al-o 
(hiriiiir  the  tir-t  jm  riod  of  the  eonlimied  liver.  I.ikeu  i-e.  dnrin;^  the 
peri.nl  of  fever-h(  i-ht,  hoth  enrve-  often  exhihit  a  >trikine-  i)aral!eli.-ni. 
In  the  amphiUilie  -taiie  ihe  pnl-e-fre<|neney  then  iieii, rally  <lecliiie>, 
-till  more  -o  in  the  period  ..f  -tr,p  curve-,  -o  tha..  if  the  tempc'fatnre 
ha-  airain  reaclii  d  the  norma!  or  ha-  fallen  IhIou  thi-.  the  pnl-e- 
lVe(|Uincv    will     he    :ejain    a|)pi .  iximalcly    n.>rmal.    al     lime-    somewhat 

llcloW,     at     oIIkI-    time-     alloM'. 

In  ireneral  it  mav  lie  -taled  that  in  the  lir-l  ilay-  of  the  afehrde 
l„,,.j,,.l  ,1„.  ,inml"r  of  pnl-.-l"ai-  more  lre(|nenll\  i-  relali\.ly  hidi 
than  low,  the    former  e-ii.cially  if  tin     hody-tenipei'atnre  al    thi-   period 

,l,,i'<  iioi  I iiir  -idMiormal.  hilt  remain-  -leadil\  at  ahont  -".T     <  '.  or  alM.ve. 

Thi-  paralleli-iii  l.eiweeii  the  pnl-e-cnrvc  and  the  lemperatnn'  i-.  accord- 
int:  to  the  pP-(  iil   -tate  of  knowled'je.  Hot   reil'rahlc  to  the  aelion  of  the 


sy.UI'TitMS  AM)  lOMl'Lli-  moss. 


latter  iipmi   tlir  licavt   :i!iil  tlic  ciinli'iv.iMiilar  s_v>t«iii,  a-  cai'licr 


wnic!'- 


■lirvcil.        I> 


(I'  tiixiii>,  which,  111   acciiii 


>th  arc  <lur   rather  tn  a  cmiinioii  cau~c,  iiaiiich,  the  ai'tioii 


lance  witli   the  intensity  nt'  the  iiiiectidii   and 
the  reactive  >ci-ce|itil)ilit_v  ot'  tlic  individual,  reaches  a  delinite  cxpre.-sicni 


ni  each    UKln  iiliial  eas 


(iiiitc  rciiiarUai)l<'  and  nut  eni]>hasi/ed  in  de-eive<l  de:_M'ee  \>y  evei 


I  some 


recent   \\  I'ltcrs 
dli^crvaiih'   il 


is   the   relaiix'c  choree  (if  inlreijiK'ncy  ot'  the   |piil-e  nt'ten 


ni'iiii:    the  a.-eent 


I' 
I    of  the    tein|)eratiirc-cnr\  (■   and    tiiron 


i-h 
mt     thi'    entire   -ta^c   ol'  continued    l'e\er.       In   other   words,    the    unls* 


in    main',    even     nioi 


h^ratcU 


V   >ev<re    and  sevire,    ease>  iUh-   not    attaii 


the    t'rei|iieii<v    that    we   are    accn-ioine(l    to    ciicoiintcr    in   other    inlec 
lion-   diseases   with    like  elevation   of   leiniieratiire.      Thi-    i-  ol)>er\i< 


especiallv    III      voiiii<r,     lohii.-t     illiiiviiliiaf-,     ill)    to    alMHit      tlic     loilieth 


vear    ot    lite,    and    more    treniieiitiv    in    men     than     in     wipineii 


tlN 


II 


M 
i|iiite   li-encrally  tlpiiiid    mider  sii'  h  circiimstances  that,  with   an  averaire 

t(i)i|)eratiire  of  .">!!'    or    In    ( '.,  and  even  more,  the  piil-c  rantre-  aim, it  S(  I 

ill    the  inorninjjr  and    lictwcen    ',i(>  a'n'    1(10  in   the  eveninjr,  rarely  ri^iiij^ 


liiiThel 


lier.      1-: 


veii  ill  the  jiresenec  of  -evere  maniflstatiuii: marked  diar- 
rhea, meteorisiii,  and  sliiiht  stii|)or — this  ciiaraeter  of  the  |nil>e  need  not 
!«'  ahseiit.  Asa  matter  of  fact,  well-marked  cases  ot  moderate  si  verit\' 
are  not  rarelv  encoiintered  in  wiiic'li  the  |)iilse-t"rc(|iienc\'  in  the  inoiniiiir 


carcelv  exceec 


Is    ti 


lal,  and    tliroiiirhoiit    the    entire    coinse  of  tl 


di-case  dcKS  not  rcai'h  \0(\  in  the  cveninfr-  I'lii^  jieciiliar  relation 
hetwceii  |)iil-e  and  fem|ieratiire  is  re-ponsil»lc  tipr  the  tiimiliar  charactel'- 
istic  apiicaniiice  (pf  the  <h;irts  ii|poii  which  jpipth  are  reiorded  ^imiilta- 
iieoii~ly    with    the    remarkalily  wide  separation    ipf   the   tw(i  curve-lines. 


Of  all    fc 


disease-,  this   relati(pii   (M'lMirs   liv  tiir  ino-t    t 


re(inei.f|v    in 


pf  typh(pid    ti'ver,  and   it    may  therefore   U'  of  itself  an   ex 


diagnostic  aid. 


As  has 


iidi 


ipp, 


celleiit 


in  scvi'ral  ci)imecliiiiis,  the  course  (pf  tiie  di-ease  in  nhh 


I'M    approximates   lliat    in    ailnlls: 


pulse   occurs   not    rarelv  m   older  clnldrcii,  allhouL'h   tli 


ilsip  the    reial 
111 


ive    nitreipieiicv  ot 
s   is   aliiiipsi    alwav; 


waiilniL''   m   ynuiiL'-er  children 
iiiaile  i)v  Kipirer.'      While,  ho 


vIiipHv  ciintirni   this   ipli-ervalicpii.  tii-t 


die   -latenieiits   of  this    writer 


ipp 


cliihlrcM  after  the  -i\tli  year,  I  iia\i'  o|p>crveil  the  plieiininennn  aliiiost  onlv 
in  tliipse  helween  llie  Iciitli  and  ihc  fnurtcenth  vear.  In  vi)Uii;icr  children, 
on  the  cipiitrary,  I  have  iphserved,  ahimsl  witlniul  exceplinn,  rather  liii^li 
i)illse-freinieiic\ . 


|- 


>r  adi 
pf  tl 


ills    Lid 


pcniieister,'   amimi:    rtrrnt  w  rilers,  eiiiplia.- 


l/r-    lliC    nitre- 


piency  ol    tjie   pulse,  and    lie   nientioiis   >au\a 


ii:es,  Ilut'elaiid,  and   lienidt 


earlier     witnesses    of     the     inanlfeslatiiHi.        Tlic    ex|'l;inali(>n    suiriresled     li\ 
l.i  •lieriueister,  that  the  typlicpid  poison  iinhiees  dirci'lK,  llinpuirh  an  iri-ilati\i 


/.v,-/,.  ,■/,, 


Irs   ,„„/.    ,/,.  /■„,/„ 


T,  i,.   ruiiv   1> 


•  %\-  ■ 


int 


TV  I'll' III)  ii:vi:n. 


eVsv 


^%^i 


..tlV.I  U|..>u  ll...  .v!,tral  luTVous  >>M.-im.  .>i..r,:,llv  th.'  ..|.'(iulla  i,i.lon-iUa. 
,li,„i,„„i„„  in  ,„il..-tiv,|U,n,.v,  apiH-m-s  I.,  inr  Mot.-wurl liv  m>wI  |,ru  ,aUr. 
(Mli.T  |,o,M„uu..-<  Mil.MaM.r.,  a.s  tl.r  Lilian  a.■i.l^  wlii.'li  .'in  iilal..  in  tlu'  l.l..n,l, 
at  tiin'-  aiv  kn.mn  to  liavr  llu'  ^an,.•  .■H.vt.  Naturallv,  iUv  ail.T.stmj; 
,,u,Mln„  i-.  l.v  im  in.'an-  « Imllv  -li.-po.-ra  ..f  hy  lli.-  l.\  iH,liicM>  nicnlinn.-.l. 
iMirtli.r.    |>..~-'iliiv   cxp.Tirn.'Mlal,   ol.M-rv  alinn>   aiv   ui-mliy   n.T.^ary. 

ll  i-  nni.uorihv  tlial  anmn-  liic  Wfll-kimun  .-arluT  ol wrvcr.-  ul  typiioKl 
iVv.r.  (il■ii-^il^Jt■l•,"l.onl^,  an. I  Munhi.-dii  cnnsidcr.Ml  intr(M|ni'ncy  nf  ilic  piil.-e 
unlv  a>  an  cxii'plinnai  cnndilion. 

With  n-anl  to  tlu'  (Hialily  nf  tlic  piil-c  in  |.Tvvic.n-ly  licaltliy, 
,-,,i.u-t  iii.livi.liiai-  ill  til.'  initial  Ma-v  aii.l  at  ihv  liri-l.t  of  tlic  .li^- 
ca-r.  it  apiM-a;--  full  ami,  partL-iilai'ly  in  the  liivt  ]<iv\,>,\.  iintal)ly  tciiM'. 
If  -prcial  I'iivmii-tancc-  ll"  n"t  aii.-c  dni-ini;-  tlic  <'nui>f  ol'  tlic  .li>yaMS 
the  pnl.c  i-  likely  I.,  ivniain  cinal  an.l  ivi.nilar  until  tlic  cii.l  of  till' 
f,.l.nl<'  pcrh"l.  At  til.'  .11(1  of  tlic  Mcon.l  ami  in  tlic  tliinl  w.rk,  in 
severe  .aM'^  earlier,  tlu  piiUc  .piitc  freiierally  is  iioie.1  to  hccoinc  softer 
without  eorr.-poii.lin--  .limiiiuti.iii  in  its  fnliw-.  Th.' .-.in>c  ..f  this  inaiii- 
f,.^,;i,i,,„_th..  iv.hi.ti..n  in  th.' t.'iiM.ai  .if  th.'  art.ria!  wall— is  ivspoii- 
>il.l..  i;,r  an.itli.'r.|nit.'  ii-nal  >iinultaii.'..ii- .'haiiL^c  in  the  pnl:-.' :   tli.'  pulse 

|„ ,n..s  ,|ier..ti<-.  -•v.n  tri.'n.tii-,  an.l   in   .■\treniely  rare  ••as.-   polycn.ti.-. 

.\l-o,  this  .•hai-a.t.-r  ..f  th.'  jiuIm'  a-:;iin  is  iin.l.aiht.iUy  inii.li  more 
fr..in.nt  in  eas.'s  of  typli..i.l  f.v.'r  than  in  tlios.' .,f  m.i-t  .itli.T  fel.rile 
(li-.aMS.  so  that,  with  many  other  writ.a-s,  1  atta.h  .liaeiiosti.'  si^niifi- 
eaii.v't..  it.  If  it  i<a.Mitionally  asso.iat.nl  with  th.'  ivlaliv  infrc.|U.'n.A- 
of  the  imU.'  ahva.ly  ni.iiti..n.'<l,  th.'  pr..l.aliility  of  tli.'  .■\ist.Miec  of 
tv|)h.>i.l   iv\i'r  is  th.nliy    ini'icasc.!. 

Th.'  .li.'i-otic  pill-.'  is  ..l)s.'rv.'<l  ni..st  frcipi.'ntly  an.l  m..-t  .listin.'tly 
in  a.lults,  ev.'ii  in  .'l.lerly  IM'rs.ms,  iinl.'-  th.'  .'xiM.n.'.'  .,f  ath.'roina 
pr.'vents  th.'  .•.,n.liti..ns  n.v.s-ary  fiir  it-  .H'.'.irren.-e.  In  .'liiKlrcn  th.- 
,iier.,ti.-  pills.:  is,  in  my  .'xp.'ri.ii.'c,  ..hs.'rvcii  loss  ('.mini..iily  an.l  h'ast 
...minionly  in  yoiiiiir  .hiMr.'ii,  ..hvion-ly  on  aee.mnt  of  the  natiii-al 
smalln.'s-  ..f  the  jiul-.',  du.'  t.i  th.'  |iliyH..l".tri.-  narr.iwness  ,,f  th.'  art.rial 
]„,„,,,.  In  ,,l.l,r  <'liil.lr.ii.  ii.-ar  th.'  a-.'  of  pnli.'ity,  I  hav.'  ..I.s.i'v.kI 
.li.'P.tiMii  n..NV  an.l  apiiii.  In  v.'ry  s.'V.iv,  an<l  .'sp.eially  in  fatal,  cases 
th.'  .li.'n.tism  ir,.„er;illy  .liminish.'-  an.l  s..oii  .li-app.ar-  .nliivly  ai  the 
li.'iirht  of  th.'  f.'V.'r.  ..wiiiir  t.)  th.'  .liiniiiiiti.iii  in  th.'  fiilnc-s  of  the 
art. 'rial  till..'  an.l  in  piiK.  -t.iisi.m.  Towanl  th.'  .ikI  of  th.-  f.liril.'  sta.ire 
in  ahn..-t  all  -.'vr.'  an.l  iii.«l.'rat.'ly  s.'V.'iv  .'a-cs.  an.l  al-.  in  inil.l  .'tiscs 
that  piiiMi.'  a  pr.itra.'tc<l  .'.mrs.',  th.'  pill-.'  lM'.'..m.-  -inall.r.  while  its 
sofin.—   pcr-i-t-.   an.l   tlw  .li.'r..ii-ni   .li-app.'ar-. 

rii,'  tinM'..f  th.'.lay  .'au-c-  n..  mat. rial  .lincrrii.-.' with  rclali..ii  1.' the 
fulnc-san.l  th.'  t.'.i-ion'  of  th.'  pul-e.  hut  all  th.'  tii'.'at.'r  .litr.'ivn.'.'  uitli 
r.'-anl   t..   th.'   fr.'.|ii.'U<'v.      It    may  Uv  stat.'tl    in   ceneral   that    th.'  .laily 


SYMITOMS   .1\7>   C'lMri.K  A  I  l').\S.  I-").', 

v:iii;iii(>ris  d'  llir  |>iil-.'  in  ca-c^  i.f  typliuiil  t'cvcr  niv  cuniicirativcly 
lilMlkril.  'I'll.'  (litl'dviir.-.  in  |)iilM-tVc-.|iiciicy  :il  tlii'  Iimiiiv  wlirii  llic> 
tcni|MTaIn;i'  i-  iiii:iii-t    iinti   :il    tiu-r  wIhmi    the   lcin|)cniliirc   i-   Imw.-i   i- 

\\Uf\\  to  III   t'l I  H>  I"  •_''!  aii'l  rvni  ;'.n  lirai-.      In  -viicnil,  tlir  lii^rli  ami 

ill.'  Iiiw  nnnilii'i-   nf  i)iil~i'-lM'al>   ami    llir   liiL:li   ami    l"\v  .l.'irri.'-  <<\'  t.'in- 

|)t'i-;ilnn'  .if   ill.'  .laily   .nrvf   (•..n-.'-|)..ntl    in   time.      If,    linwi'V.i-,    v 

fVc.|ii.iil  |nil-.'-i.li-ci'vatiiiii-  aiv  mail.'.  .|nii('  markcl  .litl'.ivii.'.-  .an  1m' 
mail.'  ..III.  .-|>.'.iallv  ..n  .lill.'r.'iit  .lay-  ami  at  .litl'.Ti'iil  liin.-  <A'  ili..  day. 
rn.liinlilcilly,  ili.'  variati..n-  in  iinlM'-tV<'.|ii.'m'y  ar.'  -li-lii.-t  in  ili..-.' 
Iiatii'iits  wli.i  ar.'  kept  ('~|M'.'ially  .|ni.'t  an.l  nmli-tmlK'.l  iii.'iitally  .'i- 
|.liv-i.allv.      In  llii-  r('-|>.'.'t — that  i-,  in    -n    far  a-  tii.y  tak.' litll.'  n.ili.'.' 

.if  wliat   L^.i.'- .Ill  ali.iiil  lli.'in .i|i.ini-.'  |ialii'nl-   rc-.'inM.'  tli.in.      'I  li.-c 

patients  aU.>  .'\liiliit  .'.nniiarativi'ly  >li,irlit  <laily  va:iali.in-,  ev.ii  wlieii 
the  fr.'.|il.'n.'V  i<  c.M-i.leialil.'  an.l  the  teli-i.m  (if  the  liilKe  i~  inerea-t'<l. 
All  .if  th.'-<'  liiets  in.licate  thai  cMernal  e.ni.lili.m-  ex.Tt  an  iiii|..irtaiil 
iiiHileiiee  ii|>.iii  the  piil-e-fre.|n.'n.'y.  In  intire  a.'.'.inl  with  this  -tale- 
inent  i>  the  fact  that  in  .'.m-.'i.iiis  patient-,  at  all  >tai:.'s  nf  th.' (li-ea>e, 
exeileiiieiit  of  the  ni.>-t  varied  kin.l  make-  its  iiilliien.'.'  ap|)areiit  in  th.' 
|iiil-e-eiirvi'.  Kverv  h.i-pital  phy-i.'iaii  is  familiar  with  tlu'  in.Tea-eil 
l're<|iien.'v  .if  the  pnl-e  .in  vi-itiiii,'  .lay-.  Nut  rarely  the  phy-ieiaii,  with 
hi-  liiiecr  .111  the  |)iil-(',  is  alile  t.i  anti.'ipate  the  wi-li  that  the  |)atient  is 
ali'iiit  t.i  expre-s,  -ini-e  the  fre.|U.'m'y  .if  the  pul-e  tli.'ii  -ml.lenly  liee.iiiies 
in.'i'eascHl.  '''his  tendeii.'V  t.)  tran-it.iry  inerea-.'  of  the  pnl-e  -hould 
nlwavs  he  home  in  min.l,  e-p.'.'ially  tVom  the  pniL'tH'Stie  -tandpoint  : 
it  is  .me  .if  the  iM-enliarities  of  the  typhoi.l  .'urM',  an.l  in  the  ahseiiee 
of  .'.iin|)lieati.ins   is  almo-t    never  .if  serious   siii^nifii'anee. 

The  eases  are  t.i  1).'  interpret. .1  .piit.'  ditlerently  anil  mor.'  seriously 
in  which,  from  tin'  oiit-.'t,  the  piil-e-fre(|iieney  emistantly  is  .•sp.'.'iiiljy 
hiirh  .ir  in  wlii.'h  th.'  piil<.'-<'iirve  r.'a.'h.'-  a  rather  hiirh  l.'v.'l  .'V.-n  at  the 
(•.iiiimeiicenn'iit  of  th.'  peri.i.l  .if  IMirile  elevation.  Fn.l.'r  -ueh  eir.'iini- 
-tan.'es  the  ilisease  mav  l«'  expected  t.i  |>nr-ni'  a  sever.'  eoiir-.'.  .\|)art 
fr.iiu  this  fa.'t,  |)irsi-i.'nt  a.'celeratioii  of  ])iil-.'-fr.'.|n.'n.'y  i-  oft.'ii  indi- 
cative .if  e.impliea;i.in-  of  mo-t  diver-e  kiml.  Tn  tlii-  .'.mni'ction 
attention  -h.ml.l  K.'  .lir.'cfe.l  e-p.'cially  t.i  inflammatory  atle.tions  .it  the 
Innirs  and  the  h.-art,  not  le--  than  t.i  th.'  p.i— iliility  .if  c.iinpli.'aliiiL'- 
|ieriionitis  and  intestinal  heimirrhatre.  With  r.fei.'n..'  t.i  the  latt.'r  tw.i 
.'.imliti.in-,  the  iml-e  is  all  the  mor.'  notew.irthy.  since  with  th.'  on  ' 
of  p.'ritoniti-  th.'  t.'mp.'ratnre  .'xhiliits  a  most  inc.instant  cliara.'ter, 
parti. 'iilarlv  .ifl.n  -liowiiiL''  no  i>levation  what. -v. t.  mii.I  al<o  that  .'on- 
-id.'i-alile  inte-tinal  heimir'-liair.'  may  .'xliihit  its  infliien."' ni).in  tlw  puis.' 
Iief.ire  the  dischar'Tc    has  taken    jilai'e    externally.      With   reference  t<> 


<  -K.-4    •   \  •" «►        — •   - 


m 


!■)(! 


rvi'ii'iin  I  III  I; 


« I  f  < 


iiili-liiial    liciii..rrli:i-.-,    it     i-    i -.iMviiillN     l..    lie    l.oinr    ill    mill.!    t'lirllicr 

l|,:ll.     ir    :ll      :lll     .mH- illrniMi  ,     lhi\      •J.IVr     vl-r     lo     r;l|li.i      lilll     ><\'    tilr     trll,- 

|M  i-atiii-r.      'I'lii-  fall  nf  iriii|>rralinv  aii'l  lin'  imrca-r  in  |iiil-.-trr.|ii.  nry 

-ivc    li-.'    In    lIlM-r    illhr-.'Clinn-    ill    lllc    rlMAC    I   l''iir.     -  I.    1>.    ---.     '  'l-'  -I1m||  ) 

til  mi  liar  I"  tin   i  \  |i.  li.  uml  .■liiiiriaii  a-  iini-l  iimu-.      'I'lial  an  ciilinly 

-iniilai-  i-i  lali"ii  l>.  ivwm  piil-r  ami  lfm|ii  ralillT  iiia\  al-u  allriiil  >lMlc  -  nl 
,-,,l|a|i-r  ..r  .plh.  I-  ni-itriii  iir.<l  ..iii\  !>.•  UK  iitinii.-.l  al  liii-  |ilar.>  |  l'"ii:.  'j:'.). 
hi  r-|Hciall\  -r\<i-c  ca-r-,  iiarlic-iilaily  llm-r  in  w  liidi  dcalli  n-iiil^ 
t'l'Miii  ilic  inlcii-ilv  iif  till'  iiiliriinn,  llir  |piil-.-.'iirvi'  ii>-i'-  all  il-  iliarac- 
!rii-iic  t'caliin-  ill  iIh'  la-t  ilay-.  and  rv.  n  ti>i-  a  iniiircr  lime  )ir<\  ioii~  I" 
ilralli  :  t'liim--  ami  icii-i'ni  iliinini-ii  a|>|invial)iy  alter  llif  ilicrdi-m  his 
alri'a(i\'    (lisipiMari'd  ;    llic    iVciim  ncy    liccuim-    ((Hi-lanllv    liiiiln  r,    «illi 


Imv  "1  til''  'li- 


Kir..  -1  -■l,.,i.i»TuIurr  .  iKirl    frc.ln   a    -.  Mr.'   .Msr  ..1   im^I.-lI    l-wr  in  a  man,  tu  riiij  ..  i,  ii   >.,.r-. 
uM.  wild  (■..;hii.>L'  Hilliuut  ilir.  t'tly  .li'iiinii>tralili'  lau-i- 

pn.LTc^-ivclv  iliniini-liiiii:  daily  fliictnatiuiis  ;  tiirdly,  tlic  ]niW  is 
wlmllv  iriTiiiilar.  -ratclv  |)al|paiilr.  and  ii.'t  to  lir  cnmitid  (  Fi^-.  14). 
Tlir  -taL''!'  "I'  drti  rvc-i-ciii'c  and  iif  alilivili'  i-diivalr-ccnri'  i-  likewise 
,],-(. rvillLT  111'  e-|iieial  eoii-ideralimi  witli  nrefenee  tu  tile  |illl-e.  sliell 
a-  lias  lieeil  Llivell  witli  ret'ereliee  t.i  the  emir-e  (.1'  the  telillieratlll-e. 
Alivadv  in  the  -laL'e  'if  ~tee|i  curve-  the  ]iill-e  fVet|iieiitly  liecomes 
^iii:il|,T  :,Md  harder,  with  iiidi-rmelne—  nr  (li-ap|>earaiiee  <<\'  the  diern- 
ti-iii.  Wiih  llie  marked  lliieliiali'ins  in  temperature,  there  oeeiir  imt 
rarelv  in  irritalil  individuals  e.irre-pnndinLi'l.v  wi<le  (liietnatinii-  in  the 
|iiil-e-,iirvi'.       More    lVe.|iiently,    howiver.    the    latter   dn    nut    e\liililt    a 

eorre-iHiiidinu'  extent    ..f  raiiL-'i'.  l>nt    tliev  may    l>e   eon-|>iei -ly  -m.aller 

than  the  teni|>eraliire-lliietiiati..iis,  >..  that    no   inofe  than  the  physiolo;,rie 
ilailv  variations  appear. 


.s)  l//'/'<Us      I  V/i    <n\iri.l<    1//".V.V. 


Wiiiic  tiiiw,  at  (lir  |Mil...l  ..I'  -I, ,  |,  .  iii\.  -,  in  |>:itir;it-  ki|^!    ] 


at  re -I    III  liol 


Ilic  iiiil-c    li\    Mil  iiii;in-    -' 


(■■•ii-Iaiil 


Iv  a-  tlic  Iciiiiii  ratlin 


Jiiliil-    llic'    iviiiilI'Mi     and     int.'rmitliil    type,    it     i-    rliaractrri/( 


iiiiii-nal   anil 


tar    nii'i'r    marl 


il    xarialiiliiv  witli    cvrrv  (li\  iati^ni    of  tli 


|)ati(iil    tfi'iii   tlic   l\  |i 
in   ''ivatlv  niliicrd    iia 


lira!   loiir-i' 


llian    in    llir  carlii  r  -ta^cs.       \'.~\> 


liciit-,    in    irntaiih'    inrn,  in    wunicii    am 


I    cliildr 


•\trin-ic  and  iiitrin-ir  inlliinirc-,  ilicin-clvi  -  in<..ii-idi  raiilr,  iiidiirc  i|intc 


l.li>   variation-    in    lln'    |inl-c-cnr\  c. 


rcmarl^a 

turn-  ■i\ar  in  li(<l 


.1-  with  till'  a|i|iriia( 


If  ilic    |iaiiiiit    -11-    n|i   I'f 
1 1  of  till    |ili\  -ician  (ir  111'  -I  ranker-, 


arriliratimi-  n 


p  to  tViiiii    lit"  III   I -"  '"'   '•'"  '■"'''  ||iiii''  tri'i|niiit. 


in    till-    lir-t    -lau'r  "f  i"nva 


il     -iilinnrinal  t('iii| 


tcinnrratnrr.  tin'   ii 


Ir-cmiT,  wliirli  \M-    liavr  ilf-i^nalril    tlial 
iil-r    in  till-   inainrilv  ul'  ra-c-  ilm-    not 


l)rcMiiic  -nlinoniial 


It    ina\,  iiiiirrii\  rr, 


an-i-iilcd    a-    a    i-nlr  .tliai     il 


n< iv.'  raii'^r-  -ihih 


w  liat   al)ii\  r  thr  Pliv- 


,S(»    Ml    till-    I -niiii. 


Ill)    til    Ititt    in    tin-  rM-nii 


dividual )  iiiiriiial,  at  alunit 
'i'lir    irali-itorv   «  idr 


II 


iirtnatiiiii 


-  dur    til  ni(-nlal  and    |ili\-iral  di-tiirliain-i-  an-  al- "  jn-t 


I-  niininiiii    a-   in  the  ,-tat;c  ut'  -trrp  i-nrM-. 
Till'   i-a-i-   ari     inrrri|ni-nt     and    nncxplaii 
if    -iilinnrnial    lriii|ii  ratnn-    tin-    pnl-i-frri|nriiry    a 


III    wliirii    III    tin-    -ta'/r 
l-.i    i-    -iiliiiiiriiial.       1 


havi-   nli-i-rvi-d    tin-    p 


il-i-  til  di 


line    111  ")<l,  I'Vrli    tn    It".  Ill    tin-    i-Miiiii'. 


and    tn   -iti    an 


1    rvni    "JS  in    till-    mill'. 


II     I-    alway-    r 
cxhiliil-    al 


iii-ini-niiii-lv    -mall    ami 


,f    till-    i-liarartrri-t 


11-      lii-rll 


I  ndi-r  -nrh    riri-iim-taiiri- 

i\\ ,    and     at     tin-    -aim-     tiiiH' 

liar    til    -tati--    ui'    i  iiiariatinn. 


I'll— ililv    in    inii-t 


llir   i-xplanatiiiii     i-    ii 


iir  iii..ki-ii  t; 


r     in    tlii- 


dirciliiii 
at    tiiiK" 


Tl 


-nliniirmil     pi 


il-i--rati-     mav     In-    nli-i-rvi-d     tn     pi-r-i-1 


fur  iinlv    a    I'rw  dav-,  at    utlii-r   ti 


—    fir  a  wrck    and    IniiL'i' 


ir  mtii  till-  pi 


riiiil    m  Willi 


Il    till'   tcinpiratun'-cnrvi'   ri-c-    tu   the    ] 


)li\-i- 


iilii'TIi-    li'\ 


■I.       1    I 


•iatimi     with     t 


ia\i'   nil- 


i-cvvrd    tlii-    infrrqiK'iiiv  i«l    thr    piil-i'    al-ii    in 
hi'     crniii'al     maniti-tatinn-    nf     infrrtinii-     inynrar- 


lili-.  uitlmnt    thr   ili-riivrry    in    tli 


•a-i'-    in    i| 


liirv  prrnlian 


tv.      Al-ii.  diirinil   tli 


1'     -ri-iillil     111 


iliii'h  till-  al n 


nallv  liiw 


iii'-tiiiii    nf  any   i  xplaiia- 

■riiid  I  if   nin\  ali-ri  'irr.    Ill 

tcin])rratiiri'  a'.;aiii  ri-r-  tn  tin-  iiniiv  idnal  li-vil, 

I'lv  nil   till'  aNrrairi'    tn  rrinain    rclatiNily  hii^h, 


ihi'    plll-l--l|-ri|llilli'V   I-    liK 

alihnii-li  always  with    a    -i"-i-ial    Imdini-y  t"  tran-itory  iiiarkn 


Hiii'ti 


liiiii-. 


Tlii-  at    tiini-  lii'i'iimi-   i" 


•iailv  alariniinr  tn   vniiiit;-  pliy-iriaiis 


the    friend-  wIhii    thr    patirlit-  1"' 
tiiiij-,  III'   -trainiiiix   at    -tm 


itli'l-    ra 

i-i'ttiii"-  lint  nf  lii'd  I'liii-idrralili'   ai'rcli'ratinii  and  in 


.'ill    In    111'    lllnli'    li\rly    ill     hi'd.   "f 

l-Ai-ii    fur   the   iir-t    ti-w  ila\-   aftrr 


-taiiility  nf  thr  piil 


arc   iinitc    ii-na 


I.       I 


n    -niiir    l>a 


ticnt-    fniirtrcii    day-   clap-i'    liclnn     ih 


irrvinii-    frriini-ni'v    a 


ml    miifnrniitv    arc     apun     attainci 


I.       In    11 


prntractcd,  c-pi 


■lallv   -cvcrc  cii; 


SI'S   tills   period    may    l>c   mure  cxii  iii 


lei. 


M 


;.;  ,11 


158 


Tyiii"ii>  iivi'.ii. 


(-  .. 


1 


i>-  *.v 


ma 


I,     ,„,.,|     -,.;UV,1v1m.     mi..,U-l     -|"rlall>    tllMl.    -n     tlw    ul,(,lr,    l-ITNinn-ly 

,„,,„„|  ,,„U,  -r.'.n.lili..n-  a,v  n-|..,v,|  tar  m..,v  rai-i.llx  in  \»■.M^)■  V"""^ 
,n,n     llian      „,     ini.al.l,,     ,,nAinu-ly    -„k     il.liN  i-IumI-     "V    «■•",.  „     a,    I 

c'liiMi'i  n. 

•I'l,,.    ,  liara.i,  ,l-lir-    ..f  ll,.'    yn\-v   .lr-.ril„  ,1    ,n-rm    1 ■\^    ni.Tr    fiv- 

,|,„,„U  .luring  .•..,nal.-r,,„,  In.,,,  is].!,-!.!  r.Awll.ai,  .l,„ii,^  tl,a.  Ii-n. 
,,l|„,-ar„„.i„r.r,i,„,-,li-,a-.-,  .-prriallv  M„al  1-|  .<  A ,  u  I  ,i.l ,  i-,,ri.„,al..l. 
ty|.l,M-  f.A',.  a„.l  ,vla|.-ii,u-  I'rx .  r,  a-  u.ll  a-  i.ii.ni„..i,ia.  ll  uiH  llms 
l'„.  ,.,.„  ll,al,  like  tl,r  -lalr..r  il„.  I  „  „  K -„„,  |m  i-al  Miv.  t  l,al  of  ll,v  |,iiUo 
i,   al-o  "I'  ii„|".itai,l    (lia-no-iic  ami    |.io-,iM-ti.-   -ii;i,ilic;ii,tc. 

|.-,,„„  ,|„.  .Iia-l,n-li.'  |",ii,l  ..f  view.  tl,c  relative  il,tVei|,,.ney  ..f  tin- 
,,nl-e  ii,  the  felM-il..  -la-e  :i„cl  tl,.'  .lien ,t i-i,i,  -.  r,e,|,,e„l  in  im  ,,tl,er 
i„r,.,.lio,i-  .11-ea-e,  „,a>  r,i,ally  a^ai,,  Ke  .„,i,l,a-i/e.l.  In  a.Mition,  tl,i> 
,|iaL:„"-ti..  M-lliliea„e,.  ..f  tl,.'  -,I.MeM  aeeel.iatinn  ..r  |„il-.-r.v.|ilel,ey 
aiteii.li,,^;  e,>n.lili..„-  -f  'ollai-e  ai,.l  va,ie.l  eni„i.lieati..i,-  ii.ay  l.e 
nealle.ir     Fi-i,,  ;i  i.,---„.>-tie  p-ii,l  ''f  vieu   it  iiiay  l.e  -aid  that  ivlative 

il,tVe,,,.e„.v   ,.r   the  pill-e.  with  - 1   vnlMl„e  a,„l  te.l-ioM  at   the  h.'i-ht  of 

tlie  .li-ea-,".    i-  of   u,mm1   -i-Ilifieai,ee.   uhih'  diefnt  i-1,1    atl'l   p.  .lyelot  i-lU  aio 

„i,l I  -,„.,aal  -iu,,illea„.v  in  pfM.-no-i-.       It    hecm,.-  a  matter  f.r  .■oi,- 

,,,,„  if  ten-io„  a„,l  vn|„„„.  ,.f  the  yy^W  fail  earlv.  AUo,  i„:.rls,.l  |„il-e- 
f,v.,,unev  at  an  earlv  period  i„  ih..  di-ea-e.  in  the  initial  Ma-e,  or  at  tli.^ 
l,euiiinin-of  ihe  f.-ti-inin.  indieat. -,  if  at  all  |,e,-.i-tent.  a -eveiv  e,„ii-e. 
Thi-  i-  ,.-|,eeiallv  tr,,e  in  the  ea-  of  men  and  elderly  individnaU.  v\hile 

,v en  and  ehililivn  in  e..|,eral  n,a.v  exhiWit  ,.on-ide,aMe  ae.'eleralion  of 

,,nKe  uithont  -erion-  -i-nitiean.-e.  l'-|v,|nei,tlv  ,v|M.at.d  aeeeleration 
,,|-  ,|„.  |„|1-,.  I,,  l:;,!  ,„■  1  1(1,  a|,;,rt  fro,,,  ehildreii.  i- o,,,ino,i-  iiii,hT  any 
,.i,v„n,-tanee-.  Nolat,.l.  .|Miekh  -nh-idini:.  marked  and  extreme  fhiet- 
iiation-  do  not  indieate  mneh,  at  !ea-t  in  the  teiminal  -ta^'e  ..r  dnrin^' 
,.,„ivale-eenee.      i;a|.id  ,levalion  of  teM,|.erat,iiv  ai,d  aeeelerali.Mi  of  |,nlM" 

,n'i-in-    -i,n,,ltaneon-ly    and    n.M    ,,nieMy    .li-ap|,earin-  are    of    jrravi- 

.im,if,ea„ee.  Intei-Mvtio,,  o|'  th.'  two  ,airve-  in  ,-iieh  a  manner  that  the 
,„d-e  i-  ureally  aeeelerat.'d  vvhiU.  the  teiniMTal  nre  .leeline-  rapi.lly  is 
evil,    ,iloie    -el'loii^. 

Irre-nl:.,ity  an,l  ine,|,-.ality  ..f  tlf  |mUe  nni-l  !.■■  eon-idere<l  a-  -rave 
-i-n- at  all  -ta-e-.  hut  mo-i  -o  nalmally  in  the  earlier.  They  are  indica- 
tive ,,f  ,-afdia,vveak„e-  and  other  i-rof.nnd  fnnetional  ,,nd-analoinie 
.|i-,,rder-  of  the  .■i,v,i!at..rv  o,-a„-.  Of  the  tvv,.,  the  iii..|iiality  i-  of 
tl,e  lar  -rearer  -i-„ilieane,\  I  riv-ularity,  e-pec'iaily  traiiMtorv  inler- 
,ni-ion.„,av  oeenr  in  the  fel.rile  -ta-e  a-  well  a-  durin-  .■onvale-een.-e 
— moivfre,|,,entlvin  vvotncM  and  ehihlre,,  than  in  men— vv  ithonl  further 
,.n„~,.|,,ei,e.-.       I  have  ol,-,rved  -nch  intermi--ion  of  the  i)tilse,  to-etluT 


wit 


h  ntanl;iti(>ii  Mini  ;ilpM"riii;il  -l..uii.-,  . -.|m  .  mllv  in  llii'  -t:it;r 


1  .-)!> 


.1    -nii- 


lioi-|ii:il   lriii|iiialiirc  . 

Changes  in  the  Heart-muse 


le.— It 


llhr    lit'    colll-r     lllllt 


the    -t;il< 


illl-r   III    no  -111 


rilllrtini|;il   acli\ilv   111 


ill  il.;;nc  ntliii-    ilii'  ("iKiiliiiii   anil    llii' 
tlir  111  art — liic  part  taken  l>y  tin    n  niaiinli  r  nl'llic 


ciri-nla' 
t'oi-r  )"• 
alfi  :iil\ 


iiv  a|i|iaraln-  i-  im 


t  vit  --iiHiririitlv  kiiiiwii — anil  it  uonlil  llnn- 


1)1;  IT,  il-i  cliaiaitif  i-  -I 
that  t'nr  tlii-  ria-nii  al 


,1,1,.  li,  ili-rn--    JH.lh  tu^rtlicf.      Sparati'   i-iiii-iili  latliiii    lia- 

Iv  liif  I  xtraiiriiii-    ica-iiii-.       in    tin'  tir-t 

Iv  felatcd  ti«  that  of  thf  t<iii|)<fatiiit-rnivc 

lillilv  ill   thr  iir-il'i|iliiin  111'  liiilll 


'II   ifivrll   lln-   |illl- 


iiir  a  ri  rtain  I'lmini 


■nir<l    nrci'--ai'v  :   a 


nil.  Ill    till'    n 


idvaiii'i's  ill  anati'iiiic  kimwli'' 


'\t     [dari',     111     ^| 
1 


^l^ill■   111'  liiafkid    rrccllt 


l^r,.   ,,f  ihr  |iril«iiiii(l  I'iiantri'-   m   I'k'   ii« 


■art 


III    ciinncrtnin    with    ty] 


ii    tvpiiuid    li'Vrr,  -1.    iittlr    i-    kii'iuii    I'lincrniiiij:   tin- 


anatiiinK ii< 

scvorc  "  iinciini|)li('a 


litiiMi-  111'  thr  iii'L''an    in    iiiil'l,  in 


rati'K   -r\rii',  anil   cmii 


K'll 


that,  wlnii  till'  «li>('a-i'   ] 


dii'-iii'^   Its   nn 


li- 


narv  ciuirsc,  any  ciiMiiifcln'ii-iiiii  ni 


till'  rrlatiiiii; 


Im'Iw It'll  till.'  JR'art  and 


the  pitlsc  and  the  aftcrial  -y-ti  in  i>  intifily  uantiii 


With   ri'trard    to   tlw  cniidition   nl'  the   lirart    in    the   iiiiiui 


il  slaiic  'if 


tvphiiid  revel-  and  t 


•vere  ca-e-,  a  -n 


l;;hiiiit   the  eiitift llf-e<it    mild   and    niiHlefately 

IVnii'iit  iinnilief  ul"  th<iriiiij:li  anatuinie   -tiidies,  paflieii- 


lai-lv  >iieli  as  will  nnel  the  i'e(|iiii'eineii 


t-   111'  niiHleni    inethiid~.  have   imt 


a-   vet   Keen    made,  mi   aeemi 


int    lit    the   relative   I'aniy 
1   di 


>r  death   at    tli 


period.       I'"i'iitll  the  ciiirK'al    and    the    phy-ieal    diaj.'MiiMie    pmiit    <il    vi 


lliitirniir  e-|)eeial   IS  apJU'eeia 


)(•  -liiiwn  ( 


lireetl 


iile   In    the   heart    in    siieh   <'a-e-.,  and,  a-  will 

-es  pui'-iiiiii:  a 


V,   Miitllllltr    I-    lll.l'le  la 


I'e   iiiieiiiii|)licateil  emirse.       Ihat, 


It   al' 
never 


II  111    iiiaiiv  ca 


tlie!e-s,  simple  "  riinetidiial 


di-(.rders  of  the  heart   and  tlu'  vaM.iiuit.ir  >y^teiii  are  not  re-pmi-ilile  tor 
haiii^c-   ill  the  piil-e,  lint  that  under  tlie-e  coiiditions 


siieli  eliaraeteri-tie  < 


at    l('a.-t    sliidit  tran-itory  ti-^siie-ehaiiire-  take   plaee.  eannot    he  dunhted. 


or  -evere   and  fatal    ea^'s  of  typhoid  fever,  however    i 

known  that  tliey  exhiliit    profonti.l    anatoinie  h'Mon-  eorres|«.nilinir  VMth 


it    lias    lon<r  iMH'ti 
ith 


the   elinieal    tnanife-tatioiis.       For    the  jin'-e 


It,  however,  tliev  eannot    lie 


hided  ill  the  description    < 


if  the  ordiiiarv  anatoinie  and   elinieal 


lend 


<iition   of  the   heart,  and   are   <'on-Mlei'e<l   a-   >evere   -| 

or  eiim])lieatinns.      Perhaps   their   relation-  are  eoiiii>aral>le   t 

fel-rile  aU)iiminiiria    to  true  tyjilioid    nephritis. 


I'ilie   loeali/atmns 


o   !hii,-e  I 


I 


leiinee   earl\'    I 


Iv    nientione<l   that    "  heart-softoniiif:       iH'eiii's   in   m 


telirile,    esnei 


-p: 


iallv   tvphoid,  -tates.      I-oiii-    ami    Stokes    also    r(vo-iii/e< 


anatoiiiiea 


Uv  and   eliiiieallv  the  oeeiirreiiee   of  iirotomid   eh'.inire' 


m   the 


heart    in    cases    o 


f   tviilioid    fcv.'r.      Kri.tlieieli'    was    tlic    first    to   call 


'   \-n-/H,mll.  ■/.  ,,/,,i~lL-n..,l    a 


riis.-h..  Wui'zluir^'.  is:,; 


ItiO 


I)  rii"it<  1 1  \  1 1: 


a- 


h 


I 


;,ll,.,,ii,,n  I,,  ill.  or.nrn  n.r  ..I  ;i,mI.  .lil:ilMli..ii  "I  llir  Ih'MI-I  in  r..|iM.rtir.li 
„;,!,    I,  s,r,  aii.l    III-   .il.-i  r\..li..ii-   ^^.■l■.■  \.  rili.'.l    K>    in:iii\    ..l,-,r\  (  r-,  :in.l 

u,iv  n,r..,|H,i;ilr.|    iiil  .  III.'  I. Mi 1-  HI  i.lall.in    .il-.    L.   lv|.lini.|   I.A.r. 

I,  i-  kiinuii  al  ill.-  |.iv-,nl  .lav  i-..-  al-..  A  nal..iiiv  i  I  lial  llu  |.n.l..nn.i 
l\|,|i,,i,l  ,||...r.|.  1-  ..r  ill.-  Ii'arl  aiv  .l.|..iHl.nl  n|...ii  |.ar.  ii.liv  l^al..n- 
,|,  ,_.,  n,  ral  i I     ill.'    iii\M.ai-.liiiiii    a-    u.ll    a-    iip'oi     nil.     iii\...'ar.liii  . 

'I'll.'    -i-nili.'aii.v    ..f  iIm-.'    .•Iiaii:;.-    in    il.lail    lia-    n..l    a-    mi   Im.ii   Inlly 

,.!,,., I,, I   ii|,.        i;.    i; I..!-;    in    in-    a.lninal.l.'    «..rL,   lia-    |ir.  .|..ii\    .all.-d 

.,,,,nli,,i,  ,,,  ||„.  f;„.|   iliiii   ilic  \arii.n-   pan  n.li\  inaL.n-    all.  lal  i..|i-    in    iIm' 

ii,\,„.;i,-,|ii,iii,  ill.'  iVi.in.nl   all.innii -  .1. -.ii.'i-al  i..n  "\'  \'ii.li..u.  lli.'  l.-> 

,,,i,,ni.'n  \va\v  .l.'j.  ;■.  I'al  i. 'ii.  llic  - 'jin.nlal  n.n  "I'  iIm  111.,  r-.  lln'  .ll\ir-c 
i,ii,.|,.;,i'  ,  lia.i'j. -.  aii.l  ill.'  liillv  .i.'-ini'iali..ii  ..t  lli.'  inv  ...'ar.linin  .an  Ik' 
r..'.,-ni/(.l  "illi   ililVaaillv    li'..!!!    lli.  ic   .Tini.al   inaiiil.'-lal  i..n-.       ri.Jial.lv 

,1,,.  |;i.|   lu,,.' lili.m-   ar.'    ni..i'.'  Iic'.|ni'iill\    r.-|..in-ili|.'    lliaii    I  li.'  ..I  In  i'- 

i;,i'  rlii.i  iiiaiiir.'-lali..ii-  ..I.mtn  .•.!  .InriiiL:  li  I''.  Tli.-  .l\.'^^^ll.'llnin-ly 
|,l■,  |,..ii.l.'ranl  ,../.  i-  plav.il  iin.|.iMlil.'.ll\  li\  ill.'  inl.T-lilial  inllaininalciry 
.,i-,„,.,„.-  lir-l  .l.'-.iiiM '■  i.x  IlaMin;'  a  liniil.'<l  -'■■/•  p..— ilil\  al-..  Ia  lii- 
-|„-.iri.'  ..Mil.  ralini:  .n.larl.Tili-  '  I'l'  llif  -'iiallr-l  arl.i-ial  l.ranrli.'-  ..f  llir 
iii\.,i'ai.linni  ami  lli.'  |h  ricai'ilinrn. 

Clinical    Symptoms    of    Typhoid    Myocarditis.— <  aniia.- 

-.Mn|.|..ni-  ..rr..n-iil.  lalilr  .li-Tir.  r.-iilllni;  tV..in  iiil!aininal..n  |.r.„'.— .- 
in  ,|i.'  ni\...'ar.rnini.  an    lik.lv  t..  Ii.'vin  al    lli.-  en. I    ..f  llir    -.■.■..nd    ..r    llif 

l„.jiniiin-  "\'  till'  iliii-'l  "'■'  1^-  iiii'l  '■■  '■'-'  '"'"  ''"■  ''""■'''  ""'■''  '"'  '■^'" 
|,,ii-cr.  A-  S|..L.-  .ail\  .'lii|.lia-i/.'.l,  lli.'  .•..n.Hli..n  1-  |.rin<'i|.all\  i.lic 
,,r  .•aniiac  u.'i'kn.'-  .'f  ral'i'l  "H-d.  ..tirii  ..f  .■..n-irlcrahl.'  .l.'-iv...  \\lii<-li 
.1...  n,,|  aluav-  a.'.'.irii  «illi  lli.'  -('\  iril  \  of  ill.  -.iiiral  ...in-.'  an. I  llic 
„K,nii;-lati..n-  ..n  lli.'  pari  ..f  "iIht  ..r-an-^  Tli.'  pnl-.'  .'-prcially 
l,....,„ii.'-  iniu-uall\    riv.|iirnl,  uilli-ul  .-..it. -p. uhliii-  ri-.'   in   l.iap.  i-alnr.', 

;in.l  ilii-  i-  parlirnlarlv  -irikin.j    in   y -.  mlm-t    in.livi.lnaU  uli..    piv- 

vi,„i-lv  lia.l  lia.l  in..ilrial.'  pul-.'-'Vi.pi.  n.'V.  Sill!  in. nv  M-nillcanI  ar.' 
ill,,  im-nlariiv  aii.l  in.'.pnlily  -f  lln'  lul-.  ,  u  Mili  nri.n  —n  app.'ar. 
ail. I  I.,  ulii.-li  lir-l  <iri.'-iii-rr  ami  mi1.-c-.,iu  nll\  iiauin  .'-pcciallv  rallnl 
.„(,.. 111.,,,  in  llii-  .■..nn.'.'li..ii.  (  >.-.-nn-in.j'  Ml  llir  ii<'i-iit  of  tlir  Llirilc 
,„  |'i,.,|.  ir  iIh'  li.'avl  \\a-  In  allliv  \>v\\,vr  tli,'  ..n-.'l  nf  tln'  ly|ilM.i.l  .li-.a-r, 
|li.'\  .'..n-liliil.'  aim. 1-1  .■iilaiii  -i-n-  ..I'  iiiip..rtanl  .•lian-r-  in  llu'  .■iiciila- 
|..rs   appavain-.      '\'<>  tli.'  a.ivl.  rali.m  an.l  inv-nlarity  .if  tlif  pnl-c  liiciv 


1  .|,'/„,7    -.,   ./.   ,"../.    Kin,.    :     /,•.■/.-■.    \'"'^-l.    I..i|-l''.    l-'i- 

». I, •,■;,,  ,/.  jilnj^.  i„,rn,.  ,i  fill,  ,  •[•    il  ,   ls.','i:   T    iii..   l^Tii, 

:iTln-  li:i-  li-'ii  'l"-''il'"'l  1''-"  I'vl'i'i'  I  I'li.-li  •■l--""-  II  M.iitii" /.'■'•'■■  ■"'■'■ 
ls^l  ,,„.!  ls>--J..  l.:.li.l"ll/,v  Mil.!  Sir.'l.\  /•"•'..  1^>--.  MlM  I-'-T  .  »liil'-  l:"liil"l'U-  «ii- 
-nn.'lv  :iM.-  1'.  .l.'in"ii-tnil''  il  i"  -|'il"  '•''  n  "-'  '""•'  ''"'  in  ^ '-n^ali'.ii. 


M  )///"i/>    i\/'  I  iivri.i'  1 1  i"\s. 


h;i 


iMc'il    M    iliiiiiiiiltii'ii     ill    Vi'liiiiii'    ami     inliti-ilv   ;    tlii'    ili('l'<>li-iii 


i-M|«|p':ii-  ;    till'    iml-c    Ikihiih-    -iiia 


ll.  ->ll. 


Mii'l    liailllv     rii|ii|ii( --Mill'. 


Ill    alirr    till'    a|i|Maraiir.'  Ill'   tin     ihaii;;''-    ill  iIh'  |>iiI-   ,  i '•  >a-iiili;ill\ 


■Mil    at    II"'    -aiiir    tunc,    -s  iniilnin- 


it'    ililatali ll'    llii'    liiart    Ihi:i 


111    ma 


iki'    tliiir    a|i|(i'ai-aiiri'.        Tlirir    ili-v  iliijiiiiiiit    ami    llirir    rMiP-iuii 
\    ;    iiiiii'li    liiiili'  I'll  iiinntK    llir\    lil'u;:!!--    i;ra(lil- 


rari'lv  taUi'    |ilai'r  ia|iii 


iv.      'I'lii'   iliialatinii    i-    like  K   al   lii-l    In    iiiMilvr    t 


III'    ll  ll    -iili'  111'  till 


iiarl.       Far  Ir--  i 
iml     lliri,    alli|ii-l 


iiiiiitiK    till'    riulit    -iili'   111    till'    ll 


ni'Ncf    III    i'iii-i 


liralil 


r    ilr'^rri', 


III 


tiiiii--  -liirlilK   iiili'i'lili'il,  al  iillirr  iiiiir^  imli-tiiii'l  ami 
mii-t  >f\  I  II' ra-i'-  Mill  al    all   ilriiiuii-l  ralili  .       1 1    \  i-ilili 
|)r('-i'iil    ill    till    tit'tli    iiitrr-paiT    in    llir   iiiaiiiiii 


II    \y 


II    al- 

1 1 

i- 

.1 

lal. 

•   ='l" 

\- 

!>.' 

ll 

i- 

lill'ii-. 

1 

Ill 

1 

ill  I 

ami 

al 

la 

111.', 

lillai'N 

1 

im 

mfi 

1  - 1 1 1(  ■; 

ti 

111 

. 

f   1 

iimfi'  tliaii  tun  liiii;!  r-liiiailtli-  lii'Vuiiil  llii-.  I  lir  ili- 
a|M'\-li('at  (•iiric-|Miii(l>  uilli  an  imi-iaM'  in  llic  ana  nl'  lanliai-  iliilni'-  In 
till'  li't'l,  wliilc  till'  illlllii'--  rili'U  I'Mi'liil-  lii'Miinl  llii'  iii;lit  IkiI'iIii-  111' till' 
-tirnmii.      'I'll  till'  li't'l    111    till'  -lirninii  ami  ii\rr  llir   -liriiiini  llif    ii|i|ii'r 


linill    lit'  cai'iliar    iliilm 


Ii 


-cvi'iT  i-a-i'-  aii~i 


--    i-    mil    raii'K    ili-|(lai'i'il    il|iuaii!. 
iillaliiiii  ili-i'|ii-('>  r\i'niliiii:l\    taint    luaii- 


lllllusl     til    llli'    |>iiilll    111'   riilll|ilrli'    <lisi|)|)raraili  r    "f   tin-    -y~|i'lii'    -nlim 


'11 


ir   -iTiiinl    aiirlii'    '-•iiiml    i~  i|iiili'   i^iiir 


•all\    cnt'ci'lilcil,  uliili-  till'  ~('i'i ml 


jpiilimiiiir  ~iiimil  at  liiiir- cxliiliil- ili-linrt  arccnliiatinii.  llii-  iiiav  nmir 
uiiiiiiiil  a  liiarl-Minniiur,  |iai'lirnlai'l\  witliutit  a  mitral  mnrmiir,  vvliich 
i-,  as  lviiiiilM'r;r  a]i|iiii|irial<lv  -talc-,  the  i'\|irc--iiiii  nt'  an  iiicrca-c  in  [dc — 
nil'  ill  till'  Ics.-cr  ciii'iilatiiiii  in  iiiii-ci|m'iici'  uf  iliticicnl  acti\ii\  mi  llic 
part  III'  the  Ict't  vcntiicli.  I'mlci'  ullnr  lii'ciim-tancc-,  in  a— ncialiuii 
uitli  tlic  ari-ciitiiatiiiii  nt'  llic  -ccmnl  |inliiiniiii'  -nnml,  lliric  i-  licard, 
iii'i.-t  (li-tiiii'lly  at  tlic  apex  n|'  tlic  luait  ni-  wifli  alnin-l  cijiial  t'rc(|iicn,'y 
iivcf  the  |iiiint  I'm'  aii-riillalinii  nl'  the  piilmniiary  arlify,  a  -\>t<ilic 
tniirmiir,  wliii'h  i-  L'lin  rally  dcpcmlint  iipnii  iclalivc  mitral  iii>;itlicicncy. 
It  is  cither  a  iliicd  iv-nlt  nt'  ililatatinn  nt'  the  Ict't  ^iili'  nl'  the  heart  ami 
nt"  its  aiirieiiliivenlrienlar  nrilicc,  nr  nt'  ilii'  impainil  aeti\ii\  nt'  the 
papillary    tnil-ele-,  nr   nt"  hntli. 

Uiiwcver  alarmin:^  these  ili-tiirlianec-  iiiav  at  time-  .ippcar,  thev 
seem  ill  fxencra'  to  he  atleiiileil  with  little  daiijrer  in  caM-  nt'  lyphnid 
It'Ver,  es|M'ci,illy  when  eniii|iare<l  with  the  anatumieally  similar  myncar- 
ditis  lit"  diphtheria.  In  the  \,ist  majnriiy  nf  cases,  aeenrdin^''  ti  nh-cr- 
vatiiMis  made  in  mv  clinic,  ciimpletc  siih-idence  nt"  the  -vniptnins  take- 
place,  ami  this  i-  ncncrallv  ai'cntnpli-hed  at  the  end  nt'  the  tilirile 
pcriixi,  at  times  even  sumewliat  earlier.  Ilie  dilatatinii  alsn  ap|M'ars 
nspally  imt  to  cnntiiiue  heymid  this  pcrind.  .'^iiirht  disturbance-  |)<'rs;>t 
nceasionally    t'nr    a    IniipT     time    witlmnt    scrimis    injury,    entirely    di^- 


1^ 


iy//^^ 


r*^-, 


162 


rvriioiii  lEVF.H. 


apiK'nriiifr  ('vcntnullv.  hi  Himc  cm-o  vvliidi  t<rinin;iif<l  fatally  tVum 
ullicl-  cniiiplicntioii^,  >:iiiic  iciiiaili--  "il  the  Miiatcunic  aitfratioii>  were  -till 
(Iciiinii-lralilc. 

Clirniiic  in\(icai<liti- <lr|Miiilinl  ii|>oii  ty]iiiniil  fcvrr,  with  of  w  itlioiit 
jM-niiaiiciit  (iilalatii'ii,  1  lia\f  a-  yil  never  (il)>erve(l  witli  certainty.  I 
knew,  iidwevei-,  that  i-i>late<l  iiiT-tani'e-  have  Itcen  .,|)iirtecl  hy  uihif- 
(Iianil<iii/\  anil  Sin<lev ,  Smnniei'-l  lenoch),  and  I  hclievo  that  on  fiii-lhcr 
(ihscvvatiiin  >lill  nihei-  will  lie  adileil. 

l'„.-i,li.-  CMC  nrrini:  at  llie  heiuhl  "I'  the  (li-<'a-e.  revere  eanliae  -yin])- 
\eMi<  mav  al-e  make  thiir  a|i|iearaMee  (Inline-  the  ~ta',^e  nt'  ediivale-eenee 
I'relM  t\l>lliiiil  lever  wilhonl  ili-lilieti\c  -yin|)t<iin-  liaxillt:'  heell  ileleete<l 
.linilli;  till'  telirile  -lau''  eVMl  ill  earet'iiUy  oli-irVe.l  ea-e-.  Attention 
ha-  alreaciv  heeii  ealletl.  ',..  the  ili-i-ll-ion  of  the  -late  of  the  ])iil-e.  to 
the  fre.|iienev  of  relalixc  aeeeleralion.  in-tal)ility,  and  irregularity  of 
the  aelioli  of  the  hearl  diiriiiLi-  eonvah-eeii'-e  without  ohjeelively  deinoli- 
stmliie  le-ion-  of  t  he  hearl. 

C;,,,.,  ,1,,,  Iriui'ver.  oeeiir.  allhoii-h  hut  rarely,'  in  which,  after 
atlaek-  of  hoili  -eveiv  and  mild  c-our-e,  u  il lioiit  cMernal  provocation, 
wilhont  auv  deinand  u|ion  hodily  acliv'ly.  with  the  i>atienl  kept  nio-1 
Mrietlv  at  re-l  in  IxkI.  from  ■me  lo  ihree  week- after  deli^rve-celice  ot 
the  fever  there  mav  appear  and  per-i-t  -erion-  di-tlirliaiiee-  of  the  pul-e, 
which  occur  oi|.rrwi-e  diiriiie  convale-cence  oiilv  after  cerlaiii  iniurioi,- 
iiirtiieiice-.  aiiil    llieii    are   hut    tnn.-ieiit.      The    markeii  accehnition    and 

the   iiTcL'iilarilv  of  the   |iul-e  Miidir  tlic-i ndilioiis  ol>tru<le   thein-elve> 

—far  lUiiiv  than  diirinir  th.'  tclirih'  |»ri."l — di-tre-iiie|y  npon  the  coii- 
-cioii-ne-- of  tli<'  patient  a- palpitalioii  of  the  hearl.  ofl.n  a-oeialc<l  with 
ahncniial  -eii-atioii-  nndernealh  the  -lernnin.  in  ihe  left  lower  niain- 
iiiarv  rcLdon  and  in  the  <  pie-a-triiim.  Not  a  few  patient-  are  eon-cion-, 
without    feeliii'.r   the    pnl-e.   ill'  every    ii.lermi-ion    in    the   ai'tion    of  the 

heart,  an<l  are  di-turlinl    therehy  a-  if  hy  heart-pain-.      'Idiere  now   - i 

develo])  the  symptom-  of  dilatation  of  tin  heart,  in  the  -a  le  way  a-  in 
a.-oeiation  with  th<-  nivoearditi-  of  the  felirile  ]ieriiid  ;  here  al-o  the 
left  nitlier  than  tie  ri-ht  -ide  of  ihe  lica'-t  i-  involv.d.  and  likewi-e 
nol    rarelv  with    -vmiitoin-   of  relative   inilral    in-ntlieiency. 

Tlie  -vmptoin-  of  tin-  myocarditi-  of  convale-cence  may  per-i>l  tor 
a  relaiiv.lv  Iodl--  lim' — I'l'  '"  two  months  ami  more.  It  i-,  however. 
iiiip.irtant  and  <'onifortini:  to  know  that  the  eondiiioii  is  alnio-t  iiiva- 
riahlv    att.ndcl    with    a   favoralile    pmirno-i-.       Kveii    in    tho-e   ea-e-    in 

I  l!..;,ili,r:,'  iirMpcrh  .nipljM-i/.-  ilii-  r.irilv  in  cnnipari-nn  willi  ilie  (iccMrniin' ..I' 
iiivicaniiti-    hiriiii:  \h>-      .uili- >liim-  "f  ilijilitlu  riu. 


.i^ 


m 


SYMIT'iMS  AM)   coMl'lJCATfiiXs: 


1  m 


wliicli  M'\crc  jrcncnil  ciriiiliitdiy  ili~tiirl):mi'('~  dcvcldp,'  witli  cviiiiu-is 
aixl    tilciiia    lit'  till'   aiiklt',-,  at   tiiiic-   i'('a(Iiiii;r  lialt-way   ii|>  tlic  caKo, 

VI vcTV  i-  likely  tu  take  place.      A  tiital  tfi'iiiinatidii  is  ccrlaiiiiy  cxcep- 

lioiial  (-(■!•  tile  laM'  III'  I jilifi'iiiri~tri',-'  ami  that  ut' /aiili/cr,'  wliicli  |M)->i- 
lily  ai~ii  lieliinjr~  in  tlii- ratc^i.ry ).  Althunirli  ^unirient  pii>l-iiiiiilciii  ilata 
licaiiiijr  iipiiii  tliis  iiiNMi'aiilitis  of  late  m  riirrciiic  arc  a^-  \  cl  wantiii}.',  it 
is  nc\ citliclcss  uniliiiiiitiil  that  the  cuiiilitiiiii  here  i~  likewise  one  of 
severe  pareiiehx  iiiatoiis  ir  iiilei'slitial  ehaiiLie  in  the  iiivoeariliiiiii  ;  and, 
it' a  eonelii-ioii  liy  analoiry  i-  periiiitteil,  interstitial  intlanmiatm-v  le-imis 
will,  as  ill  la-e-  ut' diphtheria  and  mallei  levei-,  plav  the  iiio-t  eoii-pieii- 
lill-  /v'lA.  W'hedier  the  MI\ocMldilie  »\liip|o|lls  of  Hie  period  of  eon\a- 
leseeiiee  develop  oiiK  al  this  tniie.  or  represent  a  niaiiife^tation  of 
aiiatniiiie  alteration^  in  'lie  heail-iniiMle  dexclopinu^  in-iilioii>lv  at  :iu 
earlier  period,  eaiiiiot  at  present  I"  di'<'ide<l  with  iiilaiiil\ .  Fur  the 
ina'iority   ut'  ea-e-   the   latter  ajipear-   the   inure   pioliaiile. 

The  hisliiry  of  typliiiid  alteiMlimis  of  llie  iiiyiieanliiiin  is  roiiiprelieiiileil 
in  that  of  iiiyucardilis  atlemliiiL'   infectious   iliseascs   ireueralh'.      W'liilc  piv- 

viousiy  1  Laeiiiiec,   Lmiisi   only   iinietinili iiccpiiuns  iif  the  anatomic  basis 

of  llie  cardial'  disliirlianco  in  ipiestiun  were  lielil.  and  weakness,  >■  I'lcninL', 
etc..  were  spoken  of,  llic  I'lnnlanicn!;''  work  of  \"iri'lio\v  '  iipun  parcnchvina- 
liins  intlani:iiaiiiins  tirsi  liroULrht  cicarnrss  into  this  fielil.  Snlis('i|nciitlv. 
iiolli'hci,  Walileycr,  and  Zenker'  I'lin'.iniicd  ihc  investiLMlions  into  paren- 
cliymaliins  aitcralions   in   the   licarl    in   cases  of  infci'iions  disea.se,  incJudiiiL' 

■u\s  iilhers  also  llie  typhoid  heart.  They  dci  islraled  llie  relalive  fre- 
',  icy  M.nil  occasional  intcnsi'v  of  the  parencliytiiMtons  alteralimis.  and 
altril.iilcd  the  LTcater  porlion  of  the  c'inical  syinptoins  to  t'ativ  dcu'iiiera- 
lion.      .\  new  fr       'ul  a'.dlation  was  inanLnratcd  hy  llayein'"  with  the  denion- 

stratii f  inlerslilial  inyocanlilis.      Wi.ile  I'"reiiih  iii\  csliirators  .soon  veritied 

and  aiiiplilied  his  stateinent.s.  these  received  the  appreciation  tliev  deserve 
ai iir  ( ieriiians  at    lirsl   only  at   the   hands  ot'  I/evden." 

It  is  to  tile  credit  of  Iviiiiilierir  in  (ierinanyto  have  eniphasi/ed  with 
especial  viiror  the  matters  in  ipieslioii  in  his  pnliliciiions  from  iiiv  clinic,'' 
to  have  analyzed  them  critically,  and  to  have  snp|ilenieiiteil  tliein  with 
anatomic  and  clinical  fact.s.  I->pecially  he  was  the  first  to  point  nut  the 
peculiarity  of  the  cardiac  .'Ureetinn  duriiiir  cnnvalesceiice,  and  to  atteiii|it  to 
'_'ive  a  clinical  description  of  it. 

I'ericari'itis  and  enducarditis  are  of  far  less  iiii|K(rtaiiee  in  eases  of 
lyphoid  t'ever.  Altlmnirii  in  the  inajority  of  cases  examined  anatoiiiicalK 
liy  Ivoiiilierj^"  siiialln'ell   iiitilti-ation   ot"  the  capillarv   walls  and  id'  the 

I  'I'll.'  r:i..',.r:;,.n,Til  .■.li'iiia  iiiiril  i..ni'il  l.y  .s;innii|"  I  '  h,-hi„-l,.  lid.  i.  .  i- |ir.>l.!il.lv, 
I'nun  Ihr  iKtciit.  ii>  will  n-  thi'  localization,  ii.jt  alt  in.lilc-  alon.'  to  ^lll^i-  .lur  to 
rt'rdiai'  w.-mkiu'ss.  '  .       „ssrn\<  J'(i'/i,,/,i,iir.  :lil  cd. 

■'  limine,-/,,  ,,,-lt.   l„triri,,f„:M..     1H70.  •    >-i.:-h',ir  h  An-hir.   lid.   iv. 

i  .<.•!■  tl,,'  lit.TMlur'  rili'd  by   {{oliilii'i'u',  /••<•.  '•.■/.  «  A."',  ril. 

T  /.rit./.    IJh,      M..I..    lid.    iv,.    \Sti-l.  ^I.ur.c'l. 

'  Llie.  cit. 


■M 


I 
I. 


164 


rvriioin  ii:vi:n. 


Miulh-t  v.-cN  ..<■  tlw  (i.'cp-i    Imvci-  uf  il,..  i.,.iir:inliuiM  were  piVM-.t  ill 

a.l.litioi,  t v.M-anliii-.  it  ni-.y  Mill    !»■  nuiniiaiiu-.!   ilmt    tlu-..   pHM-.'^x's 

raivlv  ;itlMin  Hirii  ;m  int.'UMly  ;iii.i  .Mint  a.  to  >/\sv  v\-v  f.  ll„.  .litiiral 
f.v.u|.l.'in-  nf  iMii.Mnliti-.  Aiiatn.iii.Mliy.  it  a!-,  iiapiun-  (Mca~iniKi!iy 
tiiat  ralluT  oMcti-iv  til.riiK.u-  .ic|."-ii-  take  piarc,  at  iiuM  a  ^ii.trlit 
in.ini.iaiH.,  .-juvialiv  -mn.un.liM-  tiu'  lar-v  v.-mI-.  1  iiavc  ol.-cfvc<l 
tlniil  i-iiranlitic  .IVii-ioii--  .mlv  wilii  v\u-vu\v  i-arity  in  .a-.^  ..f  typlicid 
Hvcr.  In  .aM's  in  \\lii'ii  I  liavc  .iIihtv.-I  tlir  .lex  rlopnicnt  ,.f  .ii-tin.'t, 
cM.n-iv...  luni;-<ontinnci  tVi.tinii  .>|-  -.vciv  .Mi.lativr  pcii.anlitis,  tlii' 
.•on.iitiun-  piTMiit  w.iv  Muli  that,  tioni  ..ti,.r  Mn.ptuni-  as  xv.ii,  tl.cy 
lia.l  tc.  !..■  ivf.mHl  to  inixcl  intivtion.  In  .aM-  of  lypi.oi.l  f.v.r  .•.-ni- 
],licat..l  l.y  tnir  -pti.-  pror,--.-.  I  iiav  in  i-,,latnl  in^tanrcs  ol.-.rviHl 
fvcn  cmiivcina  of  liic  pciicaniiniM. 

Saiv.K  nioiv  frcpimt,  at  l.a-t  .•lini.ally  .t.inon-tnil.i. .  i>  cn.l.Har- 
(iiti-.  A.vunlint;-  to  IJoniluVs  anatomic  invcMijition-.  tlii-  is  one  of  tiic 
1,.^,  .•onnnon  a<vonipaiiyint:  nrmil'fslatiop-  of  nivocar.litis,  aii<l  is  ^r,.,,,.)-- 
aliy  nroLMii/al.lc  only  n.i.roM'opiral'y.  O.runin-  ii,  small  fi-i  tiiat 
ucrasionally  .•oaU-.-c '-.n.i-ally  mni-al.  l..yoi.<l  ll><'  "ant:''  "''  the  valvrs, 
it   i~   -itnat.il   at  vari.m-   p.>ints  of  tli.'  .n.lo.anlinin,  with   csptvial    fiv- 

,,,„.„..v  in    th.'  n.i-hlHirh 1  of  th.'  .anlia.-   ap.x.      Th..  i-aiv  o.ruiTcn.r 

of  valvnlar  Ic-ioiw  ..f  the  heart  in  the  -...pun. f  typli..i.l  f.v.r  appears 

t,,    he    .l.p.n.l.Mit    np.in    th.'    niiv   anal.miie    inv..lv..m.MiI    ..f  th.'  valves. 
Contra.li.'tofv  iv|Hn-ts,  e-p,vially  .m  th.^   part  ..f  .arlier  ol,^el■v.■l■s  aiv  in 
part    i.r..l.al.iv    attrihiitahl.'    t..  th.'    fa.i    that    form.rly    r.lativ   in-ntli- 
eien.y  as  a  s.'ipwl   of  myo.ar.liti-  wa-   n..t    known,  aii.l   it  was  .•onfus.^l 
Nvith' mitral  en.l.M'ar.liti-.      Trn..  valvular  ri..l.Mar.liti-  I  have  now  an.l 
th.Mi    ..hserv.HJ    in    the    torin    of   so-.all.Kl    nl...|-:itive    en.l....ar.litis,    with 
veiTn....sc  <iei)..sits  np..ii  th.'  valve-,  ami   nh-ei-ativ.'   l..s>  of  ti-<n<..  .'itlKT 
on  the  aorti..  or  th.'  initnil  valv,  ..r  ..n  l.-.th  L.^^.^tii.T.     Th.-.'  su-rv  always 
a»..<Mat...l  with  ..tlu.r  septi.'  -ympton.-,  .^p.vially  mnltipl.'  .■.nl...li  ..f  th.' 
>kin,  ami   th.r.i.y  |.rov,Hl   th.^mM^lv,-   I.,   he   part    maiiif.-tati.Mis  of  this 
syinpt.)m-e..mi.h'N.      N..n-..plie  ..n.l.Manliti-.  t.^rminatin^^  in  rh;oi,i..  val- 
vular .li-.^ase  ..f  th..  h.ail,  o.vurr..i,  a-  iia-  I..M.n  <tat..l,  hut  ex-'.^ptionally 
in    mv   exp..ri..n,M..      W  h.th.r  sn,-h   a   .•on.liti....    i-    t..  !..■  attril.ut.il   t.. 
the  .iir-K't   aeti.Mi    ..f  tii.'  typh.ii.l   pois..n    inn-t    !.<•   r.-.'rv.il    for   future 
.{.vision.       in  mv  .'a-.'s  only  th..  left  -i.l.'  ..t'tl...  h.art  wa-  atr...-t.il.  ami, 
with  a   -in-l."  .■x.vptiou,  in  wiiL^h   th.'  aorti.'  valv.'.-   w.r.'  inv..lv.il,  th.- 
miti-:.l  valv,.  ak-n.-  was  atr,...t...l.       Kn.k.anlitis  of  th..  riuht  -i-k'  ..f  tl... 
heart  has    h,.eu  ivport.il  in  1  '■■.\<v  hy  i',.,u.hut.      Th.-.'  .a-.-  ..f  |>..ssil.l\ 
-pe.ifi..  tvph..i.l  ..n.l.H.ar.litis  .l..v..l..p,  in  my  ..xpt'i-i.-ne.-,  at  th..  li.M.irlit  "t 
,1„.  ,;,i,,ii,.  ..tajre— in  the  see.m.l  and  at  the  l)..^rinni..fr  „f  the  tl.ir.l  ^^.•.■k. 


sYMl'l'iMS  .\.\l>  <n.Mri.[r.\iti)\s. 


It;.- 


'I'licv  iMiinot  r;i~ilv  lie  (li-iiii<.'iii-lic<i  I'miii  itiyiiciinlitis  witli  iclative 
miti:il  iii-iit1iriiii(\ .  <)iil\  the  p(r~i>tciiii' nt'  llic  >ym|iti>iii-,  (>|H'cially 
the  »v>li)lic  muniiiir  at  the  a|M'X.  and  tlii'  acccntiialiuii  id'  the  >fii>ii(l 
piiliiiipiiarv  xiiiiid,  arc  iiidii  alive  of  this  (■ii<lncar(liti<'  cliai-.ictcr,  anil  tlic 
latter  will  he  (leei>i\(  1\  eiiiitiriiie<l  l>y  tlie  |M'i>i-teiice  (if  a  \alviilai'  lesinii. 
Ill  iiiieeax'  1  lielievcil  niv-elf  jii-titied  in  a>-illiiiii^  tlu' a>-i>ciate<l  preseiico 
(it' eiiildcanliti-  and  e.\ten>i\c  nivdeaiditis  in  a  ycimij.'  man  wlin,  tdfretlier 
with  elldoeafditis  flillowed  liy  iiiitnil  in-uilieieiiey  and  >teni>-is,  exhiliiteil 
al-o  syin|)t(inis  resemliliiii:  thd-e  nf  severe  an^^ina  peeturis,  witli  [Kiins 
nidiatinjr  t(i  the  e|)i^'astriillii,  tiie  iiaek,  and  tlie  left  arm.  (inite  e.\ee|)- 
tionallv — so  liir  as  I  can  recall  in  hut  'J  eaM>,  in  (nie  a  year  and  in 
aimther  a  year  and  a  half  after  an  attack  nf  typhdid  fever — I  have 
dii-erved  the  apiiearaiice  (if  the  tir-t  di-tinct  cliiiieal  syni[itdnis  (if  mitral 
insiitlieieiicy,  which  had  iki'  manife-ted  themselves  diiriiij:  the  attack  in 
the  tlirin  df  valvular  eiiddcarditis.  hut  for  wIki-c  devcldpnieut  iki  dther 
(•an>e  could  he  elicited.  1  su-peet  that  in  tlioe  cases  a  rather  exteii-ive 
niunil  enddcarditis  \v:is  present,  which  devel(i|M'd  duriii^f  the  fehrile 
peridd  of  the  attack  (if  tyi)h(ii(l  fever,  and  extended  close  to  hut  not  upon 
the  valve-.  I'hc  proi^res-ivc  cicatricial  eouli-action  that  j.n-.idiially  took 
place  in  the  iii'ocess  of  healiujx  prohahly  then  iuv(ilvi<l  |Mirti(ins  of  the 
pajiillaiv  muscle-  also,  as  well  as  the  [Miinl-  ot' atlachmcnt  of  the  valves 
and  the  teudinoii-  coi'ds,  and  in  tlii-  way  irave  li-e  to  secondary  in-iif- 
tieiencv.  Such  occurrences  seem  to  me  to  he  prohahle  also  in  otiiei 
ilcnte  iiit'ectioiH  dix-a-es  ;  especially  do  1  helieve  tlia't  valvular  lesions 
of  the  heart  developiiiir  after  apparently  uncomplicated  attacks  o." 
scarlet    fexcr   are   in    part    to   he   explaine<l    in   this   way. 

In  comiection  with  the  cliaiij.f<  s  in  the  myocardium,  a  tew  words  may 
he  appropriate  here  with  rejrard  to  state-  of  c(illa|ise  in  the  course  of 
typhoid  fever,  e-pecially  since  it  is  -till  customary  to  attrihute  them 
mainly  to  profound  chanp's  in  the  heart,  with  the  e\ce|)ti(in  of  a  few 
cases  due  to  emholism,  e-pecially  of  the  imlmonary  artii'y.  Sudden 
alarming  attacks  of  wt'akness  in  cases  of  typhoid  fever,  nntiirtnnatcly 
not  nirely  termiuatintr  fatally,  were  known  to  earlier  writers  and  were 
;;iven  careful  coii-ideratioii  dix'ades  airo.  especially  i)v  (iriessinp'r' 
and  Ackermann.-  I  have  ohserved  them  as  early  as  the  -ecoiid  week, 
at  the  heiirht  of  the  fehrile  sta>,'e,  lint  -till  more  fre(|Ueutly  toward  the 
end  of  the  fehrile  |)ei'i()d  and  duriiii;  the  peridd  df  cdiivalcscence.  I  hey 
may  occur  diice  or  sevend  time-  at  irretjidar  intervals  in  the  same 
]iatient,  at  times  without,  at  other  times  after,  direct  external  influ- 
ences.     Anionfj;  these  excitinj;  factors  helonjr  emotional  distnrhani^es  and 

'  An-lr  .1.   lleilk.   IWH.  '   y,r,-/,.„r' .  .\n-/,n:   ltd.  xxv. 


t 


m 


■p; 


Tyrii"">  I  rvyti- 


iiiil-ivt 


..x,...--iv,.  ,.l,vM.'al  .ctivilv.  -iilii.-  iii.-ot.inuv  i,.  n,-truri„m-,  rvp 
,„;.,,-  a,Hl  -innnin^  at  -tn„l.  ..,■.      Tl,.,-..  .a-.-  ar.   ^r-n-rally  ..-,„.,ully 
...v..,v    in    ul.irl,.    witliuut    clcM.un-tral.lr    ...11-.    .oUmi.m.    ai.prai-    .v.... 
,,,lv    al  liMH-  .luiinir  til.'  -•.■uM.I  w.vls.  au.l    i-  np-.a!.-!  wImI..  ImuIv  an.l 
,„i„;i  a,v  k.|.l  al.-nlnl..lv  at  nM.      'riirv  r,v,,,wnllv  trrtntnaf  latally. 
'n„,  ..|i„„.al    -v,u,,tn,u~  nf  ...,11a,.-.  atv  ti,..-.-  n-nal    ..,  — .•ail..l  a.-.,f 


^mlia.'    f.iiliiiv :    i.ail.ir   aii.l    h 


vi.litv.    .-iLviallv    1.1'    til.,    la.f    aii.l    lli«' 


..M,v.niti.-.  .Irawin-  ..f  tl...  f.atnn-.  .■..1.1  -w..at-,  .l..,a„-.iH..|iI  ..t  .■.„,- 
-.■,.„,-„.-,  tinva.lv,  -mall.  f.v.,n..nt.  ifn-nlar  fnU.'.  1  l'«  anaL.nn.. 
inv,.-.i.^ili..n-  tilt.-  thr  ma.l..  l.av..  .itluT  vaM.-l  a  ,...^at,x..  ,.-nlt.  -v. 
vvl,..n    n...v  i,av..    vi..l.l  J   a.iv  .v-.ilt    at    ail.  l.av..  .li-.i.-r.l   ,,ann..i,y,na- 

,„„-   .1 ^n.iati.m   ..f  th,'    l..-aft.  lUtly   .l.-.n.raii..n.  an.l    .liiatali..ii.       A 

,l,„,„„.i,    ,,„.ly  .,f  -M.'h  .-a-.-   l.y   in...i..n.    in..tl,...U    (  K  nl,i-l;..inlM.,-)  i> 

at  v.  I   wantiiiii-. 

■|  w..nl.l..x|m-lv  ..,ni.ha-i/..th..  fa.'t  tliat  I  i.av.-  ,viMat..lly  ..I.-.TV...1 
.l,,a,|,  i„  .■..liai.-..  witi..,iit  anv  .■xpianal..ry  alt.Tali..t.  in  tiic  l.."ly  alt.r 
.l,,.tl..  a.i.l  i.afti.nlaflv  with.,nt  .lian.^v  in  li...  ti-nn.  An:  .-l.T,  an.l  .•..t,- 
.i,,o,...v  ..f  lit.-  n.v.,..anlin,n.  If  -n.l.  .-a-.-  a,.'  tint  ii,_'l.tly  .l,-.n.-..l 
,V..n,   .■.,nM.l.Tati,.n,  i.nt    a,v   j:n.n,,..i  with   ...lav    tinva...nin^  tfan-...n-y 

,i,,.nlat.,rv  .ll.ttlfhan...-  xvith..nt    .liMi...lly  .i.^n MfaLi.'  .lian-.-  m  tli.^ 

,,.,,,,,,1,.:  .,n..-.i.,n    ..atnt-ally  afi-r- :   At-    all   ..I'  tl,.-.     ".■ar.lia.-       .It-- 
,„,l.an...s    tV..,n    ti..^   tniM.r   an.l   fan-i.-fy  t..  tli.-v   -att-n,^   tatal   .•..!- 
lap-,.    n......-afiiv   tvlMaLl..   .<•   ti...   l..afl    aL.n.V      Tlti-  .,,...-t,.,n  .-ann.,! 

1„    an-^w..n.l    n,;,....t.liti..naiiy    it,    ti...    atli.tnativ...       Kv.fy   tn.ptv,,,.  ....l 

.,l,„.m.r    will    .v....^..i/.'    lu'tv    a    .LlL-i.^.-y    in    -^-    l^.-«l.'lp'.    -I'"^''- 

,„,,l„.f.  i-  appii.'al.i..  t.ot  al..n..  t-  typi,..i.l    f..v..,..  hnt  lik..vv.-v  t..  -nniiar 
,,„„.li,i„„.  as-....iat.  .1  witl.  ..tiuT  a..nt..  itttW,!.,,.-  .h-'a-.-.     A  .nmtlK.f  -.t 

,„„,„,.,.... .nt  -,n.li,.- app...r  ...  ^lH-1    VvM  nym    thi.   -nl.j.vt.  atal   an...nfr 

,1,..,,,    ..-iH.iallv  tita.    .•a,Mi...l    .....    a.    ...y  -iini..  i.y   H.....l...r '  ».  a--.....a- 

ti„„  svitl,    Hfnitn-  a-..!    I'a-!-.-.      'H-v  l--'   ^l-.-v-.    tl.at    ti..   a-.,,...,  o 
,.„i„s  ..f  ,1...  ..Nn.i..^   air......   of  .1...    i.-K-ti....-    .li^'a-s  ..-,..r,aliy  ... 

tlu.   pn..........'...Tns  .lM..lipl,tl„.fia-l.a..;il..-.  an.l  .1,..  I'.a.iHn-  py-ryatu,,.. 

i.    ..x.,r...l,    .....    ai......    ..l«...    ttu'    l..'.»'t-    ''«'<    ^''-"    '-l"-i='".^    "l"'"    "'<; 

va-...n.......  sv-.,..n.  >..   .i.at    it.      splanati...,  ..f  .1.-  -y.,.,......M-...|.l.'^  "» 

..,„...t;.Mn.l   ;.a.-.lia,.xv<.ak,u.ss'-  i.a...ly.i-  ..f  .!..•  va............    .-   "tX"    <.. 

"    Tl,"  .'.■p'....ial   .liffi.Mtlti..^   tl.at  a.t....l  ..xp..r'm...,t<  witl.  .!..■  l-.i^.n  of 
,1„.   typi...i.l-l.a..ill..^    l.av..    Ititl,.,'...    p.vv..nt..l    a    -,H...ial    c.Np.nn..'.,tal 

■    x,Ur,.-s    l,..|^.n.    ,h,.   C.n., f   N..,,,-:,!,-,,   ..    I.u! k,    .H.^;    ,„i,,.....<   ..r  .Ih' 

, ,in..      A1-...   nrrl.,,.   U;„.    1|-.„.A  .   is:...    N..-.    M    an,l    .:!       IV.-W  ,.,M    l.n,„l,..r., 

y,r/,n„HI    ,1.   (■'Mr.  f-  >■»:.   Mr.l..   \Vi..-l.:..l..n.   W,<;  ,  ,.,W,....-.- l.y  1  h-s-I.t). 


SYMJ'niMS  .l.\l>   I  nMfl.nw  llnss. 


n; 


Stlltlv     lit'     till 


N(  \rril 


vcrllirli" 


It    i<    -caret 


it'  i\|)liiiiil    ti'M  r   M    iiiiiii 


Iv    to    ii)'   iloiiliti'ii    tliat    ii 


■irciilMtors    (li-nirl>:uiic-    arc    in 


Ir  (ii-  ill  part   I" 


lie  allriliiiliil  t"  \a-<iiiiiil(ir 


.li-I 


urUaiici- 


■f. 


wliat 


^U'\\\    till-    I-    "I 


)crali\c 


In  what    <lc- 


•  rcc   (-itfiiallv 


the  nnliiian    ty|iiia 


CNlc'llI    till 

,.i,vulal..rv    .li-tm-l.aiMv-    in    tlir    frl.ril''    -ta-v    ..f     typli.-i,!     f.Arr    aiv 


irl'cral.lc  M  -n.-li  .nn.litinn-.  .aiuKit  a-  vn  \>r  -lal.Hl  a 


l)-(iiiiiil\ .      l'"iitiin' 


,i,v.-ti-aiiMii  iiiii-t  .Ict.iniiiir  uliat  part  i-  attnlmialilf  t..  tlir  li-'art 
it-.lf,  an.l  wlial  tu  tlu-  vaH,ni..loi>,  :iii<l  fn'^'Hy  ^^''="  «"  '''*'  '•"•"'''"'■<' 
injiirioii^  iiilliifiicc  >\\'  \»i\\\. 

'  Changes  in  the  Blood-vessels,  and  their  Clinical  Mani- 
festations.—l/ml''  i-  Unowii  uilli  r.MranI  t(.  llir  art('ii.>  iVnni  rillici- 
.,„  ;,nai..ini,-  or  a  .■liiii.'al  point  of  s  irw.      A  prol.al.ly  ,-p.vilic  .li-.a>.'  of 

,|„.   artcri typlioi,!   arl.rili-   of    Knn.l,    iiivr-ti-ator i-    .-pc-iaily 

.{.■s.-rviii--  of  ni.iition.  Tliis  is  |H.-il.ly  the  |.riii(ipa;  .aii-c  of  tiiat 
ninarkalilc  .•on.lition,  ti.rtnnatrly  ,.I.-.tv.1  l.nt  raivly,  tlic  >o-<aii.'.l 
-.lH)ntaiin,u>   iranj:ivii.'  of  lli,'  .Ativniiii.-  in  the  roiir-c  of  tyjilioiil  f.'V.T. 

Til.'   t.n.l.Micy   at    piv-cnt    i-   t n-iilcr   tiic   lliroinlio-i-    as    diic   to 

an  inf.M-tiv:'  artrriti- ;  an.l  -rvmil  nivi-ti^rator.  liav  rlainu'<l  to  liav.- 
cnllivalcl  tlic  tyi.lioi.l-liacilli  from  the  walls  of  'Aw  occln.ic!  art.ric-. 
M,,r.'  nunicroiis' an.l  exact  ol,Mrvation>  are  >till  nec.lc.l  in  relation  to 
this   iniportaiit    point. 

Tvplioiii  >:aii,i;ivne  i-  oli-erve<l    particularly  in  tlic  lower  I'Xtreniities, 
aii<l  almost  always  of  one  extremity  only.      I.ar-c  iKirtion>  of  tlie  mcniher 

iiiav  1) nie   jr;.n;rn'ii<iii>  :  all    the  toe-,  tlie   enlire  foot    np  to  the    kiur, 

.veil  np  to  the  nii-l.l!"  of  the  thidi.  I'mlcr  -neh  eirenm-tance-  tlirum- 
l)osi<  will  \<r  foiin.l  ill  the  di  trilmtioii  of  the  iliac  or  femor.il  artery. 
,„•  only  in  certain  lar.cv  l.ranciic-  of  the  latter,  aniontr  which  the  [H.ste- 
rior  tiliial  artery  play-  an  esi)e<aal  rnlf. 

Tliis  peculiar  variety  of  lmiiltiiu'  wa.s,  so  far  as  I  know,  first  ile.seriiieii 
l.v  liourL'cois,'  tlieii  l.v  (ii^'on  an.l  I'atry.'  .\ii  iiiteiestini:  ease  of  bilateral 
,raiencii,~,,f  ihe  leirs  was  sliortlv  aft.rwar.l  lUH'riUe.l  liy  Racliiiiayr.'  Also, 
Tn>nss,.;ui.  ill  iiis  leiliires  at  tli.>  fani..us  .•liiii.'  at  tlie  IL'ptel  Dieii,  lias  .levote.l 
a  short  eiiapter  l.>  liiis  iiiaiiifestati.iii.  .\ni.mL'  more  recent  writers  I'otni/ 
Mereier."  an.l  Le  IJeixuiUiet  '  iiiav  he  iiienti.me.l. 

Keen.'  in  his  a.huiral.le  iiion.'.-raph.  has  .•olleete.l  ]  1.')  east's  of  ^'anjrrene 
in  tvph.ii.l  fever  .hi.'  to  art.  rial  tlir.>iiil..isis  .ir  eiiil«.lisin.  The  earlies. 
npiK'arance  of  the  sjanirrene  was  .ai  the  f.inrteenth  .lay,  the  latest  in  the 
m'Venth  we.'k.  In  tranirrene  ..f  the  hiwer  extreinilies  it  .MTiirre.l  xs  frt-- 
.piently  .-n  ti..-  ri-ht  as  .>ii   ih.-   I.ft  si.l.'.      Keen  a.lvis..s  aiiip.itati..ii  m  .ran- 

.  .\,;-h.  ,,..,.  ./,•  M,,/..  Ami:.,   l^o  '  '■"'""  "'"'■  ^''l'''  '**"'■ 

'  Ar,-/,.  ,,.   ■    .A    )/■■/..   K.'t.    iin.l  Mii;>.  IHCrv 


',l/v/i.  (Ii-  hii'I.  rr/x'r.,  1878. 


'  Cuiim  mid.,  1878. 


"   /,..,-.   ril. 


11 


SS;] 

II 

I 


'■If 


■'^Hmtt 


^^  '. 


HiH 


TYI'll'ill)   I  ivi.i:. 


ah 


ia  ■ 


•.'rem-  nf  the  <'xt  remit  iis,  ImiI  smvs  I  lint  a.<  a  ^'ciicnil  rule  it  is  Ih-mI  to 
\Miit  tor  a  iiiii' lit'  (li  iiian-alioii  ;  Iml  o|M-ralioii  sIkhiI'I  not  lie  (li't'crrc"!  \invs 
al'tiT  il>  a|p|H'araii<'c. 

I  liavf  |i(r>niiallv  (iIimtvciI  tv|iii(iiil  iraiiL'ri'in-  nf  ilu'  jnwcr  cxlniTiitv  in 
li  iiiMaiico.  Ill  niic  (  asi'  LraiiL'rt'iic  cit'  tlic  tl"it  ami  the  lower  tliinl  (if  the 
thiirii  iievelii|i<i|  in  a  |ire\  inii^ly  liealtliy  man.  tiirty-diif  years  old,  in  eiinse- 
(|n(nie  ol'  I liromlposi.-  ol'  tlie  |Ki|ilite!il  and  |Mi>ierior  tiliial  arlerie.-  (xcurriiif; 
in  the  .-lai.'e  nt'llic  ani|iliilHilic  eurve.  In  amilher  case,'  which  niciirreii  in  a 
voun;;  jlirl.  and  lerminaleil  I'atalh,  the  LraiiL'rcnc  resnilcd  Imm  ihrnmliiisis  (if 
the  iliac  and  femnral  arteries,  which  was  as.-ociated  with  liiriiMiiio|ihleliitis  of 
the  ciirres|MindinL'  veins,  and  invuKcil  liic  fimt  and  the  entire  Icl' t(i  the  hiwcr 
third  of  the  thiLdi.  The  ciiin|ilicatiiin  a|i)iiars  tii  he  extreniely  rare  in  the 
li|)|H'r  extremities.  I  have  |iersiinaily  iili.sirved  ;.'ani:rene  nf  4  linirers  (if  une 
hand  and  the  ciitanedns  cnveriiii:  (if  the  hack  (if  the  hand  in  a  |ialient  who 
esca|ied  with  his  life.  ( ianL'reiie  has  heeii  nnteij  in  isnjatcd  instances  in  the 
distrihiitidii  of  oilier  arteries  ;  thus,  in  that  of  the  external  carotid,  in  which 
ease  the  auricle,  the  jiarolid  jrland.  and  the  inte<.'ument  coverin;.'  them  mid 
the  adjacent    sot'l    parts  liccame  jj:ani.'reiioiis  and   were  exliiliate(i    il'atry'). 

I'os-iihiv  certain  cases  ot'  circnniscrihi  .1  ccrchrninalacia  ocenrrinj:  dnr'tig 
the  lerminal  stajre  of  ty|ilioid  liver  arc  to  he  atlrihiited  to  inllanimati.ry 
throinhosis  ot'  tiie  related  cerehral  arteries.  'I  l;ii-.  in  a  woman,  thirty-seven 
Years  old.  I  ohserveil  the  '_'radiial  develo]imeni  of  riirht  heinipjiresis  with 
iijihasia  dnrini:  convalescence  from  typlioiil  fever  without  antecedent  a|io- 
lilecliforin  attack,  'i'lie  case,  which  came  under  my  ohservatioii  in  con- 
sultation at  a  di>tance.  ti  rminaled  I'atally.  The  re|iort  of  the  antniL-y  hy 
the  atteiidiiiL'  plivsician  mentioned  as  the  cause  of  the  condition  extensive 
softenii.L'  of  the  niiildle  |«irtion  nf  the  left  cerehral  lieniis|ih(-re  iti  cdiise- 
(jiience  of  adhesive  throinhosis  of  tf.e  artery  of  the  fossa  of  Sylviu.s  the 
walls  of  which    were.    Iiesides.   consiiivTalily   thickened. 

Welch  '  mentions  4  other  fatal  cases  of  throinhosis  ot"  the  middle  cere- 
bral arterv  or  its  liranches  duriiiL'  typhoid  fever.  In  the  case  reported  liy 
(Xsler.  severe  Cdiiviilsions  suddenly  occurred  on  the  ninth  day  of  a  mild  case 
of  tvphoid  fever.  Death  occurre(l  in  ten  hours  after  the  onset  of  the  cere- 
hral svmptoms.  At  autopsv  there  was  tound  throinhosis  of  liranches  of  the 
middle  cerehral  arterv,  the  adjacent  lirain-siilistance  liein;:  studded  with 
heniorrhaires.  hut   not   much  softened. 

Iti  the  aorta  and  the  laruc  arterial  trunk-.  I  liave  re])eate(lly  (il)serve<l 
extetisive  reticular  tiirliiditv  of  tlie  intini.a  and  ]ila(|iies  ot'  I're-li  scler(i>is, 
licre  and  there  even  dihitatioti  (leciirrinir.  In  (Hie  case,  (k  i  iirriiiir  in 
it  man,  tliirtv-tive  vcars  old.  p*  *'ectly  liealtliy  lietlife  the  (itiset  of  tlie 
attark  of  typiioid  ti^ver.  the  arcli  ot  the  aorta,  wliicli  ])re-ented  extetisive 
retienl.ir  tliickeiiiiiix  and  tiirliidity  ot'  the  itititna.  was  (lilat(^l  to  altiiost 
(loul)le  the  nortnal.  Neither  in  this  ca-e  nor  in  the  others  iiiidir  my 
(il)servatioti  were  symptotiis  ]ifeseiit  ditrinj:  life. 

'  The  v.x^o.  wtiirli  \V!i-  iiii.liT  my  r:in'  wlun  I  wm-  ii-i-tant  at  tlif  St.  lincluis- 
>)iitalr  in  Mainz,  lia-  l.—n  r,ii..rt.(l  l.y  Ma—nll  tl>,  „/<./,.  .\,;-h.  f.  I;l,,i.  Mr,!.,  IW. 
v.,  S  ll'i  tl'.  ).  1  ill.'  ii'ii.  !i',\vrv.T.  ai,'r(>c  with  <"nM'  •■!'  th"  i'|.i'ii"n''  "■\pf--i'(l  in  ttii» 
piiptT,  ^  f.'"'    ^it. 

■'  ■  Thriiinl)i>,si.- aiil  F;nili..li.<ni, "  Alllmtt' x  Siininn  nf  Mrdiriiif.  vol.  vii.,  London, 
180;i. 


sy.MrioMs  AM)  (OMri.icATioys. 


169 


'I'lic  iil)lilci:iliii^  vixTiiil  iiiliiitis  |ircviuusly  nunti.mcd,  (!('-<  rilKil 
1)V  l/imliiii/v  :iiiil  Sircdiv,'  :iiiil  irivcii  uihIiic  iiromiiiciii'c  in  Fniivc,  i-i 
of  little  rijriiilicaiirc  I  iiiiir;iii\  itr  (liMjiiin-tiiMlly.  i  WKiild  ■•iii|)ii;i>i/i' 
«'X|ii'c's>lv  tiiat  ill  a  i:ir;:c  iiiiiiilHr  <it'  |)u-t-iiiiii1(iii  cxuiiiiiiations  in  ca^'s 
of  lv|iliiii(l  fcviT  in  wiiicli  I  imtcd  llic  cnnilitinii  (it'  tlic  corxnaiy  ai-tcrics, 
I  never  tiniml  tiiein  di^ea-ed.  In  aeconianee  witli  tlii>  uliMTVatioii,  1 
liave  alsd  ne\ .  r  eni'<iinilere<l  an).Mna  peeturi-  (apart  tVum  tiie  >in;ile  case 
already  nieiiii.nied),  either  during  the  ediirx'  of  an  attack  of  typhoid 
fever  or  anioiij^   it~   seipiel-. 

Kmholi.-iiiof  arterie-'if  moderate  iir  >n  aller  >i/.c,  of  •.vhich  marantic  (?) 
throiiil>o>i-  of  the  left  -ide  of  the  heart,  e-peeially  the  anriele,  i:.  u.-iially 
tlic  source,  i-  <|iiite  rare.  Kniholi  in  the  kidiiey>  aii<l  the  spleen  an; 
rciativelv  the  most  comnioii.  although  they  tir"  u'eiu  lldly  imattended  with 
distiiutive  svmptoms.  In  mieiase  I  ol)>ervc<l  sudden  death  dtirinj;  con- 
valescence from  tvphoiil  fever,  in  eonseipieiice  of  emholisni  of  the  basilar 
arlcrv.  Kmholisin  of  the  pulmonary  artery,  which,  aceordiiiir  to  Ilotf- 
niaini,  ipiitc  commonly  exhiliit-  whitish  tiirhidity  of  the  intiina,  follow- 
inir  tliroinl)07.i>  <if  the  rijrht  side  of  the  heart  or  the  p(r;|ilieral  veiions 
trunks,  has  already  heen  inentione<l  as  a  cause  of  .-udden  ilital  col- 
lapse. 

The  veins  arc  more  fr(i|iient]y  than  tlic  arteries  the  scat  of  disease  in 
cases  of  tvphoid  tcver.  'rhronil>o>is  of  the  larjxc  v<'ins  of  the  letj,  with 
the  finiiliar  symptoms  of  phlcjrmusia  all>a  dolen-,  is  not  an  cs|)ecially 
nire  manifestation  in  the  later  stair«'s  of  typhoiil  fever,  especially  during 
convalescence.  Kvel)  at  the  present  day  the  condition  is  ottcn  eonsid- 
eiH'd  the  expression  of  marantic  tliromhosis,  and  this  explanation  is 
pn)l)al)lv  correct  for  a  |)ortinn  of  the  cases.  On  the  other  hand,  the  dis- 
order i-  fre(|ncntlv  observed  tn  develop  in  |)revioiisly  healthy,  rohnst  indi- 
viduals aft<r  a  relatively  mild  attack,  and  in  the  aliscnce  of  |)a;-ticiilarly 
marked  emaciation.  If,  in  adtlition,  its  onset  is  attende«l  with  febrile 
symptoms,  and  often  with  cotisidcr-abK  tenderness  in  the  course  of  the 
crural  and  iliac  veins,  even  with  distinct  symptoms  of  |)oriplilebitis,  *lie 
possibility  that  the  condition  is  dependent  not  niwm  a  simple  thrombo- 
sis, l.nt  n\vm  an  inflammatory  state  of  the  wall  of  the  V(>in,  must  be 
taken  into  consideration.  Whether  such  typhoid  jihlebitis  is  s|MHafic 
and  is  attributable  to  tlu'  direct  activity  of  the  l)a<'illiis  of  Eberth  is  not 
yet  certain,  but  it  is  not  im])robablc  from  the  observations  that  have 
l)een  made  in  so  many  other  orjrans.  That  other  micro-orfranisms  also, 
es]H'eial!v  py()<;en:c  ciK-ci,  may  |)articipate  in  this  prin-css,  that  therefore 
'  See  the  section  on  Anutoinio  Alterations  in  the  Cir('uluti>ry  Organs. 


=•  >-    -.       -  • 


170 


ryrii"ii>  ii.viii. 


,,,,„„,,li,,„i„.   ,,l,l..l,iti.   in   .I,.  Mri.t    MM-, may  o...ur,  ...n  s,.:,r.-.lv  1.- 
,l..iil.l..l   afl.r   the   ol,HivMti,.n-   nf   Dunii..' 

Lik,.    ,v,.l>wi,i   .rt.rin-.    ,,1,1.-.,..-!;.    all.a    .Inl.n-    ^  n.rally    a,.|..M.-- 
„,„„,    ,„„'-i.lr.        In    nnlv    -2    in-tan.r-    l,av..    1    „1.-,  n  ..1    tl,.    -.r,,,,.! 


tim,'   r.|uallv  .(l.nialou-,  ..hvioii-ly    ni   <-<.n-. 
;,nl'„,v"or   .M.nMon  of   tl,.    tli.n.nUoM.    f.    tl,..    luu.r    portion    ..f   tl.e 
i„,-,.,i,„.   v.na   rava.  an.l    lii-n.-..   t<.   li.'   otinr   iiiar    vrn>. 

■n,..  v.noM-  ol,Mn„iion>  in  thr  .■ -•  of  t,v,,i,oi,l   f,  vrr  a.v  nn.lrr  all 

,i,,,„n.la..,v~   n,o-,  nn,l,-iral.lr  ,o,n,.li.-a.ion-.       it  i-  Irur  tlia.    ,v.-ov...-v 
nMially    follou-.   l.nt    ti,r   .iuratio,,    .\-  llir   .H-a-r    i-   r,,n~Hl.TaMy    pro- 

,r,rt..ci  •   not  raiviv  tor  a-  nni.h  a-  tuo  or  ti.r.v  n.ontl,-,  an.l  rvm  v. 

1    l,,v,.   no,  ol,-..rvr,;   .an-rmr  .l.vrio,.   a- a  -r.,n.l,  l.u,  now  a.i.l  auain. 
,;,,,„„„..ly    ranly,   .l.taMun.n,    of    fraj:„u.n,s    of    tl..   tln-o.nl,..-   o.T..rs 

witli   fatal   .■Mil.oli-iii.  ,         ,     •         !■ 

N,„    „,   tin ,l,o-i-of  ,1„.    f.moral  v.in.  plilrhitis  at.-I   .hvIumom  ot 

,h.-  -at.lu.non-  v,in  alonr.  or  of  ,1,..  ,.o,,lit.ai  v,in  an,l  ,1.-  .l.vp  vrm^  ot 
,1„,  „„.-l.-  of  tlw  .alf,  will,  .■•l.-.na  of  th,.  f.-t  up  I"  >!„■  .alt.  an.l  .-jK- 
,i,ll.-  with  tirtn  intiltrali.m  an.l  ..on-i.l.fal.l.'  t..n,l..rn,.--  ..I  tl,..  nu»..l..s. 
,:.„.  ,„  ,„,  ,„„  nnv.  In  i-..iat...l  in-tan,v>  1  liav..  ..i.-.rv...l  also 
,,l,l,,,i,i,  ,„.l  p,  ripl,l..l.i,i-  .n  ..1.1  vari.-o-..  .lila.ation- of  tl,..  v..n,-  ..t  .!»• 
;,.„  i„   ,„„„  ,„.l  w.,.n,.n   M.tV.rin,^  fn.n,  ^^\^^«\>\   f.v.r.      in   ,ny  .Ap-n- 

,,;,.,.    v...,on-  ,hron,l..,M-  in  tli.'  ..onr..  ..f ->  pi^.i'l  f.-.r  l.a- nrn-l  ..tl, 

,.x...".Kli,..r  n.ritv  in  otl,.-  p.-ti..,,-  ..f  .I..'  l-b  tl.a..  tl...  l..w..r  ...xt.vn..- 
ti„.  1„  on.,  in-tan.v  tl...  axilla.-v  v.i,,  a...l  i,.  a>,..tl„.r  tl„.  r.^.t  -nl.- 
..l.via..  v..in  wa-  inv,.lv...i.  IVm.!-..  lik.'  -nany  ...1..  r  wnfrs.  1  Lav 
,„„i,...l  ..,«,.,  in  wl.i.l.  pl.l.i.iti-  :»..l  tl..-...„l...M-  NV..V  p:Hl  n.an.i.'sta- 
ti.,„-   .,f,   or   a..tnally   tl.c   s-mnr  ior,   g..,.,",!    s..pti....i...a   .■.,n.ph..ating 

tvi)l..>i.l   f..v.'i-.  .       ,       X- 

■    Changes  in  the  Condition  of  the  Blood.-N..,.,.nm>  s tato- 

ntontswith   .v^anl   t..  tl...   .•..n.li.i..n  of  tl.^   l-l-"!    i"   -<-;^  'M''';"! 

f,.v..r  atv  ......tain...!    in   tl...  writi-.-s   of  .a.li.r    .1  -.•rv..i>.       I  L.y  ivt..r, 

l,„„-..v..r,  0..1V  t.,  tl...   ..v...,'nal   app..a,-an.v-   ..f  I-I.-hI   .•l.tan....l  on  v.t.o- 

.,.,.ti..n   .>r   iV...n   tl...  -l-'a.l    l..Hly  ..r  that    ..-..apinii   a.-..,.l..ntally        Ih.^o 
.,h<..rvati...is  ,li..l..-.Kl   ...   littl,.  that    f.-r  a   l.-nj:   tin,.'   tl...   M...ly  .,t  the 

1,1 1    was    alt..L'...h..v    .....l.-t.^l.       NVitl>    tl..'    a.l.M.ti.m    ..f    .n.,.r..v..l 

n,..tl..Hls    s,...h    inv,.-ti^ations    hav..    .-.•.■..ntly    h.-n    n.-.n....!    ^v.th   .n..ro 
.„o,...s<      Tl...   .„..,-pl'"l"irv  uf  tl...   M.H«1   an.l   .v.-tai..   ..l....n..'al   .•l.a..,tr.. 

i„   it    parti-nlarlv  tl,.'  l..-havior  .,f  th.  lu..„..,irl..l.i...  Lav  1 n   stn-h.^l, 

.,„,!   .,„  M   ..onsi.h.ration   has  l„v„   jriv..,,  t..  l.a..t..,i..l..ir,.'  .nv<.st,jrat,..n 
Changes  in  the  Formed   Elements  of  the  Blood.-W  ith    rcganl 
I  /),„/>,•;,.  .l/v/,./  Uni^  M'.l..  M.  \\\i\,.  U.'l't..  :;  >i.  4. 


SYMrniMS   -l-V"    (  OMI'I.II    \lloSS. 


171 


t.,  tl..-  n.l  l.l,KKl-.or,,nH.l.s,  t!..-s,.  Imi  n.nly  ,xl.il.il  nurk,.!  rl,.n_-.  s 
i„  r,,n„  «i/.r,  an.l  .ul-.r,  hut  tlu  ir  .num.rai-n  I,:,-  v,..ia,.l  i,..t  miuhi.t- 
,.-,i„.^  n-ult-.      Wl.il.  .■Mil-ur  vN.-it.i-.  .-|H.i:.ll>    M^ilM"-/.  an.l    ll^.v.in, 

v^.,,v    ummI.I..   tu   .1... ..^tnu.a   .v.lu.non    i,.    .l.ir   >nnMlHr.  ,....-.    n-,,. 

writ.T-  1..V..  lumul  tlut  ii.  tlir  majority  of  -a-..-  tl,r  nuinlMr  ot    n-l  ,o,- 
,,„-..l..-  nn.l,  ru-^  -louK  ,.o,.n-iv..  .v.luHiou  .iMrin,  .!.•  Irl-nlr  ,,,  ,,o.l. 
Kvl.l.n,...    in    -u,.,H.n  of  ,l,i~    -tat.nw  nt    i~   .■..nUm...l    m,    tl.r   ar.,,!.-  o| 
Zi-l.in'   Ti.n.av  Hm11:'.'=""1    l.i.l.,.  n^urn,'  a.pl  a-   a    .vmiIi    o|    ,,I,-,.>- 
vation-  M.a.l..  in  n.v  .  linir  I  an.  in  a.vonl  wi.l.  tl,<M,.     W  .■  al-o  ol.-.rv,. 
,,...,„.,,•,„    i„   ,,u.   nnn.lur  of  ,v.l  Ml-,  .v.m  fn.n   tl.-  iK.^innn..^  o(   ,!,.■ 
,;.l,nl..    ,u.ri.«l.      Tl,i<    n.ln-.ion    1.   pn.n.Uy    AVM    i"    -'M'^.    -'"'-> 
..,,>.    -o  that    .!.■  nnn.l-r  >till   ,..,"='11<^1   »•"""•""" '"■  -'■""■^^''^"    """•'' 
^vl.il..  in  noMMi.  an.l  .Khilita...,!    i,„livi,lual-  a  n.ln-tion  ...  ^;.<><"M";'  -• 
evu,  s..n,..wl.at    1.-  ...■.nm.l.      Tl.ay.r.'  fn.in  an  analy-.,  ..t  all  l.l.....l- 
,o„„t. -n  tv,,l...i.l  i-aticnts  in   tlu.  .I..ln>-    ll..l.kiM-   H-l-'tal  -Innn.Ml... 

,a-,  ..i..v..,;  v..a.s  .,at..  tl.at   th.  av.ra,.  l..>^  i-  al t   1  .M.n.oot.  ,... 

'.,„,n       'riu.'.v,lnrti..n    .■..ntinn..-   t..    in.Mva-..    nn.il    towanl   tl...   .n,     ,.t 

„„,  ,-,|.,il,.  p..ri.«l.  a.,.l  .v....   int..  .1...  af-l.-il.'   p.-i...!-      1"  »•='-'-  ""';"^' 

,,„,„i„„,  how..v..,-.  n....n,.n,ti,.n  n.ay  l..,'in  w.U  l..r..re  ti.e  h,.1  ot  .l..1.r- 

v.-.vn.r.      Dn.in-  .•..nvaU-.v..,'..,  n-nally  Iron,   .w.,  ...  tl.n.c  w.rk-  atUT 
,K.f,.rv.-<..n.v.  tl...  .nnni..r  i<  lik.ly  ...  .■.■.nrn  ...  .!..■  normal.     1.  appears 

l,„w..v..r,.ha.  .!..■  nn.nl...r..f  r,.l  l,l,-..l-....r,.n-..l...  ,.i,y>i..l..poallv  n.,nnal 

to  ,1...   in.livi.lnal   is  l.ut   >l..wly  attain,..!.      W..   l.av..  faih.l  to  t,n.l  .1...- 
„„,,nal    ..nn.l..T   i.i    ,«iti.nts    wi...   l.a.l    lurn   In-   iV..n.    f.v.r  t..r  ..v.n 
...v..n  w..ks.      Witl.  tl...  ...Ki't  ..»■  r..lai.s..s,  .1...  .nnnl...r  ...  r,.l  l.l.-..l-.-r- 

,,n-..l,.-vvill..f...n   l...f..nn.l    sn.all..r   than   .Inrin-  th.' <i.M  f.l.nh'  l^-n.-l 
nf  .1...  .li-..aM..     This  is  .,l,vi....4y  .hu.  ...  .!..■  .■.nn.ihitiv..  («.■.•.-  ..I   .ho 

two   itcri.Hl-. 

An  intcivstinjr  (•ircniu-taii..i.  nici 

in  . 

sini(.   indivi.liial   timing'   tlu.   ...iirso  ... 

iturv  inm.uso  in  the  nn.nh.r  t..  tl...  .'Nt-.n.  ..f  :M),m^\  aiul  ,'svn 


t.nti..nf(i  hy  various  ..hscrvcrs  consists 
in  .i,^almal  vaH=.ti..ns    in   tlw   .unnl.,.r  ..f  nA  l.l.HHl-<...r,.ns..l,.s  in   the 

.f  the   fever.      We   have  ..hst.rvt^l 


a  transit 

of  1,()00,()0(). 

but  ..nlv  a  relative   iner(.ase,  in  e..ns«nien( 


I'n.hahlv  ini.ler  sneh   eiivnn.-lan<...s  there  is  n..t  a  real, 


that   is,   in   th(.  ani..nnt    ..f    water   e 


.(.  of  vai-ia.i..ns  in  den-i.y — 

_ .ntaine.1   in   .he   1.1. hhI.      Thus,   we 

haNVii.."ie.Kl""s„eii"an"ai.i.arent   ine,-eas,.   in   tl...  n.nnher  ..f  nnl  1,1.....!- 

.  /„„,,,.  /)-■-..  B..-1.  1*^H'-  '  ^"""•''-  ■''■'•''•■^-  "'"■  ■""'     '■"'    '"■ 

'  /'-(V.  f.   lli-'ilk.,  \\A.  iv,  ,        ;„„ 

<.!■,'      .1  .,  ,n,    uhrr   ■!    lT;h<vn1-l>h,n,halt  lies   lilutes  im    r,esi,H.kn  u.    knmkm 

»  Koliier.  /"""/;.  />'«..  T-.'ip.-i>'.  W»->. 
*Juh>,s  llupknis  Ilu^,,.  Rep.,  vol.  viii. 


U^^Sml^^BM^J/iWf^JmSXi^Stm^^^^M^Ji 


172 


/I  riiniii  1 1:\  i:i: 


Hi!) 


H. 


HI 


I 


,.,„■,„.-,  lr-;,ri(r  i.n.lM-..   -u.ati..-.      Cn.uii/'  I.m^  ol,-..|s.-.i   tl..^  -]>,nU'- 

,r,-:ivils   ..f  ill,-  M I.  iui'l  ih.rc  toiv  it-  .l.i.-ily,  in.-n  m^.'  iil'tcr  cl.l  l,;illi^, 

uuii.-.   ;.-    Ii'-  roriv.llv    iHlirx,-,  to   llir   .ir.Tt  \Nlii.l.   -liini.hnion   of  tlic 

v;i-uni.,„„-  u,  rxcii-   ^V-t.Kl  -Arrl-  u\<'<u  tlir    vnmI.p- M.Mt    o|-  tl,,.   1.1 1. 

l',,s-il,lv  -iMl.inrt,!-.  ";.-  to  tlir  rrhlivr  iiMT.a-.-  in  lli.'  innulMi-  of  iv.l 
l,l,,o.|-,or|Mi-.li- 111  ll.r  iMiriniiiii:.'  of  ill,,  f.l.rilr  inii,..!  ;uv  :itlnlml;il.l.' 
,.,  intlii.n.T-  lliiil  al  tiiiu-  j:iv    li-    to  a  iv.iiuti.m    in    tl.r  tliii-i-   of  the 

'll„.  ntlii.ti,.n  in  ilir  i-ivinta-r  of  li,in,.i:lol,in    in   llic  1.1.«h1  'Inrinir 
tlu'  f.hrilc  iMii,»l  aiip-ai-  to  .•,,irr~iM,n.l  uilli,  l.nt  in  no  .v.nt  to  .■x.v,,!, 
that  in  tl,.nnnil„rof  n.l  l,loo.l-,-,,riMi-,l.- (<  inin-kr,.       Tliat  tlii-  iclii.- 
ti,,n,  li,.w.vtT,  i~   i'"t    -on-tant,  an,l    l-v  ii,.  nuan-.  .•,,ii-i.irial.lc,  i-  ^-In-wn 
|,y  111,-  n.-ativ  ,.I.MTvati,.n>  ,,f  L.•i.■llt.■ll^ti•^,.      In   mv  .•lini.',  av.raK"' 
ml„.ii,,ii-  t,>  from  SO  t,.  T:.  \»v  ,-.nt.  liav,'   l.r.n  oI.mtvcI,  n.ivlv  i,.wer 
f,;r„n-.      In  tlu.  af.lnil.'  lM>i-l.  .-l"viallv  .luiintr  thr  fn>t  wr,l<<  ,.f  tins 
l„"n,,.l.  all  ,,l.-.iv,T-,  iiHliMlinu;  j...i,.l,t.Mi-urn,,.l.>.M-vr,l  a  lomr  prnvnt- 
a,r,.    ,,|    li,.in,,irl-l.iii    than    .iiirini:    the    f.'l.fih'    i«'fio,l,   ihi-   M;;ain   ror- 
,v-,,oii,liii-    with    thr   irnau-t    .v.iii.-ti,.n    in    the   ninnlMr   of  .v.!    l.lo,,(l- 
,.„,.,,u,..h.s  wi.i.'h  uMially  ,..vni~  M    thi>   -tajr.'.      Kaaihr  ■  -tafs— aiul  m 
thi-  Wf  <"m  MLMv..  with  him  ni-on  tli.'  Imm^  of  |„TH>iial  rxpvn.iKr— that 
,hirin-  .•onval.'XTiu'.s  vvhil.'  the  niimlH.|-  ,,f  iv.l  l.loo,l-,.,,ri.n-..l.-  i^  ajiain 
i„  ,,ro.r^s  of  in.'tvaM',  a   fmth.T   mliicti..!.    in   th,-   p.iv.ntajrr  "f  hnn,,- 
irlohin    mav   tak.   I-Kkv.      It    ,.vol,al.ly  n-nallv   ha,.,..->   that    wluiv   ih. 
',,„Mnia  ha>  l»rn  a,.i.n-ial.l.  th.  ivtiirn  of  ti...  hciuvlohi,,  to  th.  norma 
is,  a.   in    most   s.ron.lary  unemia,-,  n.-.tv   KMa.hial   than    tiuit   ot   tl...   .v.l 
l)loo(l-i-o|-piisi'h>s 


III    cimiwnson 


witli   what   i-   known  coiUMrninjr  the  itnkocytos  in 


oth.r  iMf....tious  <lisoas,.s.  th-  state  <.f  the  white  l,lo.Kl-eon.us<.le.s  ilnnn- 
tv,,h,.i.l  lever  is  striking.  NVltik'  i-  the  majority  of  a.-ite  inieetions 
,ii.,.as,.s  the  whit..  l,l.KMl-eor,.,.>.les  are  funn.l  inerea^.I  at  the  l.-.^^ht  ot^ 
th..  attaek,  tin-  in.Tea-e  i.  Mantins:  with  ^reat  e,.nMan,.y  tn  eases  ot 
tvphoi.!  h.v..r;  a  .limini.tion,  win,!,  may  even  he  very  ...uiMaerahle  ,s 
.il^,.n  ,.re..nt  (llalla-rnina-,-  v,.i.  F,iml.e..k/  Ki...ler;M  in.w.t/ ■  Nae^eh, 
Tinv.  r  '■)  It  eve..  ha,.I.e.,S  as  Kie.ler  show..,I,  that,  with  ...eivase  ...  the 
sv.npton,.   of  the  .li^euMS    with    mark.nl    elevation   of  the   te,„,.e,-,tu.-e, 

;„.!  with   tl ..set  ..f  .•e.T...l..«'enees,  the   .......her  of  white   1.1 U'ov- 

,,..i,.s  nn.ler s  still  further  .-eanetioi,.      We  have  a.T.ve.1  at  the  same 


p.. 

^  l,,^    ,;t  »/,'/.,/■.  llrltk..  Bd.  x. 


'  A7.H.  VnllfJ.  il.  Hi.if 
!,nr.  rJt. 


SYMri'lMS     IN/'    '  (iMri  l<    \  ll'iSS. 


173 


inclii-iiiii-'   a 


S      111 


>l. 


.(•rvers    li;lili<<l 


llil  II 


i!!-. 


\hr 


uccMirirm 


,i'  iii.rca-iil  ndiiiliiiii  in  tlic  iiuni 


li,  r  111'  till'  liiiUmMi-  willi 


(•\:iri  riKiiiii"^  " 


.1'  tl 


II     ll!iriim|illiM 


till 


iliiriiijr 


the    tilirilr    -t;!!'!'    \m 


till  1 1 II 


tVi.Iil  ".MIUUi 


Kx: 


rli:iti 


t,,  -JiMiO  whiw  l.liM.<l-<i,ri.iiMli-  ill  tlif  riil>i>'  iiiilliiixl'i-- 
it  raiilv  pivi-  li-f  tu  a  tiiitlii  r  n 


t'    tllr  ill-ia-i'   II 


iliU'ti 


1,1'    1(1(1(1.       (  'iiillll-  aliiivr 


lo  (1(1(1  arc  i-art',  ami  ii-iiaiiv  iiuliratf  llic  miM-t 


lit'  siiiiir  iiiiii|ilii'atiiiii 

has  -liiiwii  liiat  111 

iimiil.1  Till' liiikiiivti-  ill  till'  jM  ri|)iifi-al 


the  itVfit   lit'  Miiiif  1'iin'ii.Mi 


itli 


Tl 


lavcr 


III  lialli'  raii-i'  an  iliiinn 


li:itc  tiaii-itiit   inirt-.iM'   in   llif 


iilatiiiii 


( 


ii|)licatii>ns  wiili 


mil    riilH 
ill 


litiiin-    lliat    nnlinarilv 


five    riM' 


tl)   Iciikiii'vtii^i-  ail'  altcni 


In! 


witli  an  iinTia-i'    in 


till.   nnnihi'T  nf  white  .■..rpi.Mli-  tu  tln'  iiufiiial   ami 


iIhiVc 


11 


111    wit 


111-,  III  a  i"i-i'  II 
1     till'    iIi'M'IkjiIiii 


r  iiiliTi'iirniit  iimniminia  llji*"'  wcii' cinii 
lit  lit'   an  al)-i'("— 


ivir    till'  >ai'i'ii 


itfil, 


III    4W0,  iw 


('iiiii|)art'<l  with   2H>()   i.ri'vinii 


As  tl)  the  ftVcct  lit'  lit 


-ail 


tl 


iiTc  IS  a  tcmlciifv 


her  I'l.mplii'atiiins   iiixm   the  U'likocytcs,  it  may 

,  though  ot'ton 
twi'lvc 


ilh 


1  that  iK'im.rrhajro  may  fX.Tciso  Httlc  i.r  im  iiitlm'm< 
ti.wanl  a  ItMikocvtnsis  nwhin^r  its  max 


(imnm 


to  twenty 


-t'oiir  hours  at'tcr  tlic  hfimirrliajrc  has  occiirrc 


•latci 


1  with  a  li'iikucvti 


.1.       Th 


Tiic  hchiivior 


rDiniHisis 


)f  th 


anil  i>lilfl>iti^  afc  asMx 

white   coipii-eles    in    pert'oi-atiun    i-   uf  izn-M    impuitaiiee,    esi.ei'ially    ii> 

riiaver  eoiieliules  tVom  quite  fVei|iielit   ar 


relation  to  earlv  iliafrim^i^ 


aei'Unite  eiuints  oil 


H  eases  that  pert'onitioii   oi'  the  Imi 


ill 


iisiiallv  lol- 


OWll 


1  l)V  an  iiierea-e  m  the  nun 


iiher  of  leiikoevtes  in  the  |ien| 


ihenil 


eir- 


iilation. 


'I'll 


lis  luav  he  eoiisu 


in  eomparison  with  previous  eo 


iler.ihle  or  only  sli^'ht,  ami  appreiialile  only 
Not  intreiineiitlv,  however,  there 


nuit.- 


lll   aliseiiee   ot 


1- 

evtes  mav  oeeii 


inerease  ;   e 


veil  a  (liinimition  m  the  num 


iiher  of  leiiko- 


r   the  latter  heiiit:  ireneniUv  an   im 


lieatiou   (jf  tile   malig- 


III 


tv  of  tlie  iufeetion  or  the  prostnitioii  of  the  patient. 


No  ilistiiiet  (litfereuee  in  the  ii'duetion   m   the  mini 


ilxT  of  tlie  white 


eorpuseles  in  aeeon 


lam 


ith  tl 


le  seven 


at  least  not  in  sueli  a  <le<rree   that   i)ro^nii 


tv  of  the  attaek  apjK'ars  to  occur, 
-tic  conclusions  can  he  drawn. 


In 


mv   eliiiii 


recovcrv    en 


-mil,   for    instance,    in    a   case 


111     w 


hi.'h 


■<luetion  to    U<ll"   occurn 


.1.      While,    therefore,  no    sjxH'ial    profrm^'ti 


lifrnificance    can 


corpuscle^ 


th 


he    attachi'il     to    eiiiime 
)ri>ce<liire    is,  nevi 


ration    of    the    white    hlood- 
rtheless,  not   witlunit    sifrnifieaiiee    in 

that    are 


litt'erential    diapn'sis,   particularly   with    reirard    to    d 
iistantlv   attend    1    with    marke<l    increase 


i)lo<KWorpii 


ejitic  ])i 


the    numher   of   while 

les,  and  that  occasion  difficulties  elinically.      Pneumonia, 

utionwl  in  this 


•esses,  and  cerebrospinal  meniiifritis   may  be 


conneetiim. 


71 


I)  lll'iih   I  I  17  /; 


PS 


"1 


I 


li  1-  M]r|>ri»iiiL'  lli:ii  I'll  iiIimt\ii'  liki-  \  iii'liiiH  ri-|>.irl-  an  iiicnM»i-  in  ilio 
l<'nl\iH'\  it'»  III  I\  pliohl  li'Nri',  ami  tin-  <|ii('>ti>>n  ari-iT-  w  licllicr  lii.-<  olix  rv  aliuii!* 
air  II  liralili'  hi  iIh  niilial  .ila;.'i-.  Kniirli  iii\  oli^'alm.-,  a.-,  liir  in-lanrr, 
liniiiii-,'  liaM'  riMiml  I  oii-ii|cralili'  iiiiTfa.-i'  ■liiriiiL'  lln'  lir.«l  «i-(k,  and  nnly 
.-iili-i'ijiK  III  Iv  a  rajii'l  ii>'(  I'raM' in  llir  iiiiiiiImI'  i'I    wliili'  lili'<Ml-i'iir|inM'lo. 

1  >iiriii;^  I  lie  I  Mil.  "I  III'  ,iiii\  all  -(  iiici  tin  I  Mini  I II  r  nf  li  iiImii\  n  -  a|i|iiar- 
a'^aiii  til  iini'ia-i'  -InuU  ;  aiicj  in  i|i  liiJilaltij  |iir-iiii-,  ariiiiilliiL;  '"  mM' 
iiii-i  r\  at  ii  III' ,  iiiiiir  -jiiwh    llian    in    inliii-l    iiii|i\  iijiiaU.  in  wliniii   ullin    a 

Irtlini    til    ill'     lliiinial    lna\     In     llntiil    ilnllll'^     (jrlrlV  i  -i  mrr     III'    ijlirilli;     till' 

tii-t  ali  iiilli'  ila\-.  in  i-nlaliil  in-iain'i -,  Kiiliiir -'  n  lali  -  lia\  iiiL'  "li- 
■cfMij  iliiiiiiL:  iii|i\  all  -iilii  1,    \ulliiiiit   c-|iiriai  a|i|iari'lil    caii-i  ,  tran-ili'iv 

iiiiii  a-f  in  till    nniniK  I'  nj'   wLiir  |i| |-,„|'|,i|.,.|c,  ;ili.i\,    tin    |ili\ -inl.ii;  ir, 

1 1|  I  In  rj, I  111!  I.  Ill  I.  Ill'  in-taiiri  I  \  III  n|i  til  I  7.")l  I".  I  In-  nlj-nx  at  ii  m  i- 
-n|i|i'iiti  i|   ill  a   fiiiiai  kaliic  inaniicr  li\    a  -iinilar   hIi-cia  al  inii    nl'    Laailir. 

A-  In  liir  \arialiiiii-  wliiili  nrnir  in  llir  fi'lalivc  iimiiiIhi'  uI'  llir 
ilitliiviil  \aiiili(-  III'  liiiNiirx  ti -.  TliaM-r  ■  -a\  -  tlnii-  aii'  llini'  inaili 
clian^ji-.  ami  ntlnr  aiit  limit  ir-  ai;ii-r  uitli  liiin  in  llic  i^viiiial  -taliimnl-. 
(-11-   Nariivli  'l. 

ij)  i'liiii  i-  a  |ifii'^i'i --i\  !■  (liiniiiiitiiiii  in  tlir  |m  irciitaLri'  "''  jinU- 
iiiiir|iliiiiiiii'lrai-. 

( l! )  riirn-  i-  a  jiniLiir— 1\  i  ninca-i  in  lln  |M'iciiita^r  nl  iniimiiiiiilrar 
liifin-.   till'  im  rra-i'  liriii;.'   inaiiiK    in  tlir  lai'i^r  nin'inniiclraf  varirlii-. 

(:'il    A   ciin-taiit  l\    -mall   [icn  i  iitaL:''  "I    >  I'-iimiiliilii'  iill-  uri-iif*. 

Nac'Liili  tliiiik-  llial  tlic  in-imi|iliili-  ii-i  all\  iiitiiilv  ili-a|i|iiaf  ilnriiiLr 
llii-  liii'jlil  nl'  tlir  I'rMT,  ami  llial  tliiii  |i(i-i-ii'mi'  i-  a  viiy  t-isnralilr 
|ii-iiMnn~tic   -i'jii. 

Bacteriolo}jy  of   the    BI(kh1.  —  SimT    tin'    tiim-   nl'  ( JalVUv .  iintmi'niis 

nli-il-MT-    have   (ItAiitcl!    tllcln-C'K  c-    In     till'    ill\  c-ti-alinll    nl'    lllr    Mnnll    |iif 

inirin-niuaiii-iii-.  |iarliriilarly  ty|iliimi-liarilli,  (Jatl'ky  liiin-ilt',  ti-  i- 
kiinwii,  nlilaimij  m;^ati\i'  ri-iilt-  in  lii- ii'.Mi  in\  i-lii^atinii-  in  tlii~  clinc- 
liiiii.       I,alir    iii\ c-tiLiatiii-    lia\i'    ilinitnl    tlirir   -tiiiric-    in    pari    In    ijif 

lAainiiialinii  nl'  the    lil I    nlitaimd    I'l-nin    -nim     inii\  cniiiil    jial'l    nl'  liic 

Imilv.  Mciiifallv  llir  li|>  III'  till'  liii'^rr.  ami  in  |>art  In  an  iiiv«-lii;:iliiiii  nf 
thai  nlilaitiiij  t'lnin  rrrlaiii  parN  nl'  ilic  lindy  iIh'  xat  nf  -prcilir  Ir-imi-, 
c-pcriallv  lllr  fn-cnia'.  'I'lli'  fc-illt-  air  uiiirlv  (li\  i  ri;rllt.  ami  ill  pari 
aiT  niarknilv  ciiiilfailiclnfv.  W'liili  .  liir  iti-Iaiicf,  Mii--rl  '  liniml 
Ivpliniil-liacilli  ill  llic  liluixi  inii-Iaiilly  in  It  ca-r-  rxainimii  tin-  tlii- 
|iiirpiiM',  iillnr-.  a-,  tin'  iii-lamT.  Alnii|iii-t "  ami  Silvc-triiii,"  lia\i'  liriii 
alilc   In   (Iniinii-trMlc   tlniii    ntilv     in    i-nlalcil     iii-Iancc-,      ( )li-cr\(i>  nf 


Th..,-  .1-  J;,r,<.   I,s7i;. 
'  /,...■    ,-it. 
•  (iiiti-liiTLT.    iNK.'i. 


■'  /,.„■  .-.I.  '  /. ■-'. 

»  II';, ».  I,,,'/.  II'm,-/,.,  issi;,  N,„.  L'l  unil  l':!. 
'  Ji,r.  .,,„    .//  I'/i/i.  I'..,/  .   IMi:;. 


M.)//'/".I/>      I  V/)    <  OMI'I  l<\  IHiSS 


17« 


•  ■-|Mri;il    -kill,    -ikIi   ,1-    Kriiiki  I    ami   Sin I-,'   ;iN.i     Lupil.lio -'   and 

Sit/,  lia\i,  Imwis.r,  jii-i  a-  ijid  (iallkv,  in\aiiall>  olilainiij  mj^alivi' 
ri'-nii-. 

Newer  wink  willi  l)elt(r    ttietlicKJ-.   Iia-,  lnn\e\ei-,  -Ijunmi   that,  in-lcjiil 

iif  I\  |iliiii<l-lpaeilli  iiceniiin^'  mily  e\,e|itiiiiialiy  in  the  l>l I,  (lies  pmlialilv 

ale  |ne-int  in  e\  c  l\  c-.i-e  liniin;:  -iinie  -lai^e  111'  tile  c|i-ea-e,  .111(1  ean  lie 
<lenii.n-tiale.|  in  a  inajoiity  nf  all  the  ea-e-  if  |ni.|H  r  iMeilii.iU  in  making 
en  It  II  le-  ate  ein|ilii\  ill.  (  'nle,'  liv  n-illL'  ei  iil-iileralile  •  u.init  -  o|  lili  muI  ini  I 
(iilntiiiL'  MIX  l:ir.:.|y  in  liijiiiil  ine.li.i.  wa-  alile  t...,  ■  uii-lrati'  tlic'  liaeijli 
ill  II  "lit  iif  I")  ea-e-  e\aininit|.  In  'p  mI'  ||ii-(  ea-e-  ili<  liaeilli  Wile 
iilllKateij  iVnlll  the  IiIm.mI  In  I'iiIV  the  Wiilal  le-l  wa-  |Mi-ili\e,  -i  i  that  tlie 
liielhiMl  ha-  enii.ideraljje  I'iatjiiu-lie  iNi)...iianee.  The-e  le-nit-  have 
-iliee  lieell  eoiiliiineil  on  nil  .1  r.pii-  ppiIiii  la-i-  at  the  .iiihii-  l|(p|pkill- 
lli>-|iital. 

S-Jippttiiinller  h,i-  lalelv  .>|piaiiie<l  tiii'  Ipaeilli  tVipiii  the  (irenlatiiif,' 
IpIipipiI  ip|  til  (Pill  (pT  "pH  ea-e-  e\aininnl  Ipv  hiiii.  Aim  liaeli  anil  I'liirer'' 
ie|..p|t  |HP-iii\e  le-iilt-  ill  7  (Hit  ..f  I  n  ea-i-.  aiiij  ( 'a-teiiaiii  ha-  iiiiti- 
valiil   the  haiilli   tViPlll   the   IpIipipiI  ..r    I -J  iPlIt   ipf    I   t   ea-e-. 

ill  tile  -aiiie  way  a-    with  iviranl   In    'Xiiiiiin.itinii-   ol'  tile    M I    pji- 

erally,  iili-erver- ilitl'ei- al-ip  \\  ith  ivreiene.'  tip  the  |pre-inee  nf  liaeilli  in 
the    ty|iliipiil     rip-eul.e.       It    W.I-    hipjieil    at    tii-l    that     the    -tmlv     ul'    ihi-e 

^tl•Ul■tll|•e-   ininht   yield     ilii|Hprlallt     ri-lllt-.        it    Wi.nlil    liplllptedlv    lie  lit' 

.feat  diairilip-tie  -iLrililie.inee  tip  lie  alile  tip  deinipii-tl-ate  the  -[leeitie  liaeteria 
ill  the  t'rei|llelit  eliaraeti  li-tie  .lltel-atinll-  ill  the  -kill.  The-e  hippe-  have, 
llipwiver,  lli.t  lieeli  Inlly  le.ili/ed.  It  j-  line  Nellhail- '  lielieved  th.it  he 
had  ileiiiipii-trated  them  in  nupri  ihaii  hail'  nf  the  ea-e-  examined  liv 
illlll  (ill  !l  III'  l."i  liatiillt-)  ill  liliHiil  tViilll  the  r..-ep.la'.  Opimsed  to  him, 
lliiwever,  ai-e    the    entirely   lle;.rative    re-llIt-    nf    die    iili-irver<     |.reviiill-l\ 

tiieiitiiined,     Friiiikel     and    Simm 1-,    .Sit/,     i,iii.r:itellii,    (',:\{\k\     and 

.laiiiiwski.'' 

Hiiwever,  within  the  |ia-t  few  yeai-  the  )rei|iient,  pniiialilv  eunstant, 
jireseiiee  nf  ty|.hiiiil-l)aeilli  in  tjie  ru-e-puts  ha-  liirn  dciiKinsti-ateil  liv 
.\eiifel<l,('iii'-elimaiiii,,anil  iJieliai'd-uii  in  ."pL'  mit  of  |()  eases  friim  wliieli 
cillfiiri-  were  made  liy  these  iiliservcrs.  K.  l-'Winkel  lias  also  demmi- 
.stniled  their  pre^eiiee  in  s,>etiiiiis  iif  the  iii-e-|>,,ts  (sec  sc<'tiiiii  mi  J)i- 
cii— inn  nf  the  I iiiiividiiai   i''eatiircs — I{o.se<ila). 


I  ''\\ 
f'i 


'  A.K-.  ot. 


<■  Hull    .rJ.,,.-  //.y,Av,,  //,:../,,,  ^,ll.   xii  .  N,,.  124. 

•■  n,;its.h  ,„r,i   n;„-h..  au-.  !•,  I'.toii. 

'  ""■'■■  "'•'■•  '''■  '■•<»"'•  '  li<f.  wr,i.,  v,,l.  i.,  Nos.  6  and  7. 

••  Hi'i-hn.  /ill, I.  H'.„7(..  iHKi;,  N,,-.  0  ami  i;4.  'A,,,-,  nt. 


17G 


ryriinin  i  i.vi:i:. 


1 


w 


III  addiliiMI  til  cNMIuilKllinli  iif   ll i  rcll  l;il  i  HIT  lil I  llll'l  tlic  rn-c()lii>, 

attclltiull     llll-   lltfll     «lilr,lc(l     mI-c,    \„    the     Ii1(hmI   (if    llll'     -|.I(CII.         I'n-ilivf 

rt-iilt-  cuiilil  iiio-i   ica-ciiia!ilv  l.r  r\|icci(il  I'loiii  tlii-,  m~  it   i-  will  kimwii 
lliat    cxaiiiinaliiiii    ut'    the    >|ilinic    |>iil|i   al'liT   clcaili    ti^r    liacilli    aliii<i-l 

:iluav~  \  ii'M-   |«.-iti\c   n-iill-.      Ai i:    tlic  tii--t  w  In.  uhtaiiiiHl   |Hi-ili\c 

n-iilt-   from   llic   i\aiiiiiiatiou   uf    llic   1)1 1   <<\'  llir    -iilcrii    (lining-    life 

arc    ('liaiitciiit»c    and     W  idal,'      liid.iiliariK  i,-     lMiili|i<)U  ii/,'    and     K. 

Nci<-iT.'      Atlclii|it>  wii'c   made   \<>  iilili/c   llu-c    tindiiii; .did    Nri«>cr 

liiid  till-  i-]«via!lv  in  view — \'i<v  jiMfjMi-c-  ul  caily  diaLMio-i-.  1  liilicxc 
tliat  tlicrc  arc  ^criini-  (pliicctiuu-  tn  llii-  |irai'ticc.  In  llic  tiivt  jilac.-, 
tiic  i-c>n'it~  i.i  i|Uc-tiiin  arc  li\  im  mean-  cuii-taiil,  a-  llic  uli>crvaticiii-  ut 
Stai;iiitta,'  tin'  cxainiilc,  -Imw  ;  and  cxcn  if  llii-  uci'c  nut  llic  ca  c,  llic 
daiiiicr  (if  llic  iPidccdiirc  wdiild  -land  In  llic  way  of  its  ciii]il(iynicnl. 
One  iictKl  lint  think  of  llic  tcn>cly  di-iciidcd  >|p1c«'II  nftiMi  oli-crvcd  after 
dcatli.  witli  the  -iiclchcd  and  tliinncd-nnl  ca|i-nle,  and  mImi  nf  the 
iciidcncv  ,  whitji  i-  liy  i;  i  lucan-  ^li■:hl,  Im  -|i(intanc(in>  ni|iliii-c,  and  "iic 
will  iidl  cM'aiiL'  the  fear  that  piinciiirc  nf  the  -plccn  dnriiii:  life  may 
readilv  result  in  rii|itnrc  and  danirenin-  hcmnrrhap'.  1  have  iievt  r 
lieen  alile  to  inaUe   np  my    iiiiiid   tn   |ierfiiriii   the  (iiicr-ttioii." 


':  v't-' „; 


SPLEEN  AND  THYROID  GLAND. 
Enlargement  of  the  Spleen. — A1i1iihii:Ii  recent   enlaivcment 

(if  the  >|ilecn,   (ili\ii>n-l\    a    nianife>tali f    the   infectidiis   |iriiccs-,    is 

(ili>er\cd  ill  all  iiitcdiiiii-  di-ea^e-.  IK  \  (  rtliclo-.  a|>art  fidiii  nialavial 
li'Vi  T-  and  -c|ilic  di-ea-.-.  -]ileiiic  liiiiicr  i-  in  no  di-ca-e  (if  a-  j:reat  dia^'- 
iKi-tic  >iLniili(aiicc  a-  in  typhiiid  fever.  Thi-  lint  ha- even  jrivcii  rise  to 
exatrtrcratimi  iif  iIk'  value  of  the -ym|ii(ini.  Smie  pli  .siciaiis  will  iKit 
venture  a  diaLnm-i-  "l'  ivplmid  fi  vcr  at  al'  uithinit  the  (lcni(iii>traticMi  of 
fnlan/einent  of  the  -iilccn.  In  addition  to  the  frc(|iieii<y  of  eiilarp'- 
niciit  of  the  -|ilccii.  it-  early  o-cnrrciicc,  ii-  relatively  li.n>:  duration,  and 
its  coii-tant  rca|iiicaniiici  in  rccrudc-cencc-  and  rclapM'-  arc  e-|iccially 
indicative  of  ty|ilioid  fc\  i  r. 

The    frci|Uclicv    of    typhoid    clilarp-mcnt    of    the    >plccn    in    c-eiieral 


I  /,. 


'  /--/.  r  /,/■//,  .1/.'/.,  lid.  N-\iii 


«  IC/,„.  ,„,,/    lil.tlt,-!-,  IssCi.   N.i-    i;  iui.l  7 

=    /,'    ("     ti.'.l  .    IS'.IIK 

«  Al.,,      N.i-.,.,'    (Il:i..lkc.     ■Ilii'    IliiiL'ii'"''    'I'-    .\l.il-n,i>i;,ll\pliil-    illiil    \Vi.l:ils 

Soriiiii.liM-i,..-ii-rli.-    \-.Tnil.r.ii  ■     /)..-/m/,      .„../     ir../.  ,    Is'iT.    N..    L' i   \\n-   r lalv 

r(.p..rtc(|    tli:il    :it    |,n-nt    li.    |..rf.inii-   |.iii„  luiv  of  tli.-   -i,],  ,1,  f,.r  ,li:,.,Mi.i-li.-   |.iir|..-— 
,.nlv   ill    llic   nin-t   .11-.-.    -11;. ■,     h.^    Iki.I   f..un.|    ..11    |.o-t- rlr \Miiiin:ili..ii    "f   "nc 

|.;iti.-nl    ..„    «||M1,!    ;hr    M|„.rMll..ll    ilii.l    l.r.'Il    1  ..M-l'.  .rin-.l   li    lili.'    l-iir.   11",  rlH.    ji.Mi;,    ill    tlic 

(■ii|i-iil'-  ■•I'  iIm    -|,1.i-ii.    uimI    11X1  L.'niiiis  nf  II 1   in   tln'  iil.il.iiiiiiiiil   ciivity. 


mmmm:  m^^^mmmMmr  ^Wij^mi^w^mmf^  ^^^m$m>&^ 


KYMI'T'iMS  AM)   <  OM  ri.K    [  IIOSS. 


177 


<';iriiini  lie  otiiiiMicil  Villi  ccrtiiiiily  t'riiiii  tile  I'oiilts  ot' cliiiiciil  I'xaiiiiiia- 
tiiMi.  A>  will  l)c  .lire  fully  iliMii--c<i  laltr,  its  <ltiiicin>tratiiiii  at  tlic 
l)<il~ii|i'  is  allciiilcfl  witli  \aiiiiii-  ditliiiiltii's,  so  that,  it'  a  triistwurtlis- 
ciiiiilii-iiiii  i-  lii-irnl,  the  aid  <>|'  anatuiiiic  <il)M'r\atii>ii  iiiii.-t  In- 
liiviiktHl.  Ill  Vdiiiii.'-,  rnlm^t  iiidiviiluals,  wlicii  death  ncciirs  at  tht' 
hcijiht  or  lowai-d  the  (  iid  of'  the  di-ca-c,  cmii  a  ~liort  time  attcf  tlu; 
oii-ct  ol'  dcti'ivc-cciii'i',  iiiorc  or  it'»  rociit  ii\  iicrciiiia  <if  tlic  spU'cii  is 
nircly  uaiitiiiir.  In  icmilpriiiity  with  cliiiiral  cxixiiciicc,  lioucvcr,  and 
to  this  extent  aUo  availaliie  in  exaniinatioii  and  diajfiiosis,  is  the  filet 
that  in  cases  ot'  typhoid  t'e\er  nuHlentii'  sized  spkiiie  tiiiiiors  arc  tiir 
more  tVei|iieiit  than  cspceially  larj^c  one-.  I']iiiarj,reinent  of  the  uriraii 
to  (loiilde  the  normal  or  to  two  and  a  half  times  the  noi'inal  is  the  rule, 
three  times  the  normal  volume  lieiii};  sumewhat  les-  eoninion.  Tht' 
niaximnm  si/e  has  prohahly  heen  re|Mirteil  liy  Kokitaiiskv  as  six  times 
tlie   I'.livsioloirie. 

The  eiilari;i'iiieiit  of  tile  spleen  is  likely  to  he  irreatest  at  the  hei^rht 
of  the  disease,  while  at  the  eommeiieemeiit  and  in  the  periinl  of  steep 
curves  or  on  the  first  afeltrile  days  its  vohime  is  less.  In  tho  later 
stajjes  of  convalescence  eidurj;ciiieiit  of  the  spleen  is  pn  nt  only  excep- 
tionally. 

I'licliiiililedly,  the  iiieiin  si/e  of  the  si)leiiie  eidargeiapiit  varies,  like  many 
other  syiiiptoiiis  ot'  tyjilioid  fe\fr.  in  ditt'ereiit  epidemics.  I  liave  noted 
perioijs  in  which,  aiiatoinically  an<l  clinically,  the  eidurfrement  of  tho  spleen 
was  sliirht ;  and  others,  for  instance  the  llatiihiirir  epiileiiiie  of  1M8()-  1«M7,  in 
which  ail  unusual  iiuiuIht  of  liirjre  splenic  tumors  were  ol)serve(l.  Of  l?00 
successive  autopsies  of  which  1  have  notes,  there  were  f<iuiid  excee.liii^'ly 
larjre  tumors  in  127,  iniil  tumors  of  miNlerate  i'lid  coiisiderahle  size  in  173. 
In  no  ca.sc  was  eiilariiemeiit  of  the  spleen  watitinir.  In  lx-i|.sic,  on  the  other 
hand,  anion;;  I'll  aut  ip-ies  on  ca.ses  ot'  typhoid  fever,  there  were  ohserved 
exi'ee(liii;rly  lar;.'e  tumors  in  4"),  tumors  of  moileriite  size  in  11."),  small 
tumors  in  21,  and  alisence  of  splenic  eiilar^'ement  in  .iO.  The  tulile  of 
Hoffmann  shouhl  also  he  inusnlted. 

When  ( idar<rcmeiit  of  the  spleen  is  \vantiii>r 'lurinf;  the  febrile  jhtIimI, 
this  is  de|)eii<lent  in  tl;c  majority  of  cases  uixui  sjieeial  conditions.  Thus, 
in  advanceil  life,  or  in  youn^--  or  middle-a^ed  iiulividiials  when  the 
attack  of  typhoid  i(>v<r  has  heeii  preceiled  lt\-  diseases  attendisl  with 
marked  emaciation,  enlar^'cnieiit  of  the  spleen  is  freipiently  wantinjj 
thron^diont  the  entire  course  of  the  disea.se  and  iiixm  jxist-inoftein 
examination.  The  conditions  last  named  jrive  rise  thither  to  atropliv 
ol  the  spleen,  and  if  then  inli'ctioiis  enlarp'iiient  of  the  oripin  takeis 
place  at  all,  Jiis  will  he  jli.st  .siiflicient  to  restore  it  to  its  phvsiolofrie 
si/e. 

At    times,    antecedent    dise-ise   of    the    sple^-n    itself    mav    prevent 

12 


W^m'^'Mi^^T^'^^  ife 


Si 


Ih' 


17H  rvriioii)  ii:\i:r. 

..nlarpMMnt  nf  tl.,.  urir;iM  in  l.v|.lini.l  i.vrr.  Tlni-.  tlir  -yhuU-  fis.u.- 
nus   i..'    thf    -.;lt   nf  ri.Mtlirial  <ll.lll-c.   in  r..M-c.Mil.Mr,uf   iHwioU-    hv'^v 

,„.  "i,,,,!,!!,!,,  inthniiuM  ;  ..!■  ii-  .hi-ti.iiv  may  !.<■  inipMind  l.v  .Immic 
,litr,„..  ,.,„„nvtiv.-.i--n..  l,y,M-,.laHa  ..  l.v  u  i.l.-|.iva,l  iullaninialurv 
tl.i.k.niM-uf  it-  .ap-Mlr.  I'.rl.:i|.>  in  tl..^  .•on.litinn-  laM  nam.-l  may 
n-i.l.'  tluMxplanatinn  ..f  n,y  ,,!,-,  nation  that  vvlui.  typlioi-l  f.v.r  ur.i.i- 

t;„.  ,1„.  -,., 1  ni-  tlir  lliinl  time   in  lli"  siiiic  patient    .nlaipm.  tit  ot    lli. 

.,,l,...n  i-  Mli-rni  witii  ivn.aikaMr  Wvunrury .  Finally,  it  -linnl.l  l.r 
„„.„,i.,n..l  tliat  i.iMluMa.iif  lamuiTl.a-c  may  canx'  fapiil  .liininnti.m  in 
tl,..  >m-  of  an  .•nlai-cl  i>l'- n-  l-l—i^iHv  wli.i.  <l<';>lli  «'-"l'>  t^'"" 
,,n,tn-.  int.-tinal  iMtnoifliap'  1-  thr  -|.lrrn  f.mn.l  imt  faivlv  of  t.uftnai 
>!/.•,  I>iit  ivmarkalily  y.il:  tlaiihy.  an.l  w  linUi.d. 

'I'lic   al.-vii...  ,,r  -plriiii'  tnmnr  uitlinnt  .Ir iMfaKIr  i;'M-r  i-,  .Infitij.: 

tiw  f.liiilc  Ma-r  of  tlir  .li-.a-r,  an  ( Ativmrly  laiv  anatoiiiic  r.Mi.lition.  I 
hav  mv-rlf,  it  i-  tt-n..  .x.vptioiially  mad.^  tiii-  ol.-ivation  in  yonnfr 
,H.,>on>'  hnt  tii.n  iIh^  pan-nrhy n,a  of  thr  -pl.rn  Nva-  iiMially  nt  l.Mst 
i,l,„...-mallv  itviHivmi..  -oft,  an.l   KnlLnn-.  tmi-,  in   m   .•otulitioi.  of  a.-ntf 

tn.n-iti.m:    in    J    .a--,    in    la-t,    iv.'.nt    .•ot.M.l.faM.'   .■Nt,avaMiti..ns   ot 

l)lo...l    w.i-.'    foMiiil    in    ill.'   -|vl<-.n. 

Anmm:  :.77   aut.,,.M.>  ■  llatul.m-,   L..i|.M,-'.  1    Io.m.I  al..,,...  ,.f  >,.letnc 

,„laf...MK.nt   ,mt.-.l  in  4'...      If  iVotn  tl,...  ......  a, v  .  ..hut.-l  .Ih...   m  «ln. 

..,„,  of  tl...  fii<.t..rs  nam.Ml  •     |.l:m,.-.l   ih-  .•..m.I.im.u.  t  ,.r..  i-...,.an,  hut   .•-!.< 

^r  .•'■nt    ..fall   <•=..--    in    -In^h   .■nlMrz.nu.nt   ..f   ,!,..  .,,l....n    uu.    «M„l.njr 

.luriiiL'   tl...   f.'l.ril..  ^IML'..   «illH...t    .1.  n,..nslral.l..  .Mu^f. 

.,•,,,   „i,i,„„,  ,,„.-.■    of  tyi.l.oi.l    ..nla.-vn>.nt    ..f  tl...   ^l-l......   Mtt.l    tl.o 

.,„...ial  .......lition-  f.,r   it-  ...vniT.......  aiv.  a-  y.  t.  unkn.,vv,..      Tl...  ..ailnT 

assnn.,.tion  that    tl..-  pv-vxia  alon.-  Nva-  tl„.   .•.■-,.o,..il.l,.  th.t..r    tnnM    .■.■.-■ 

fiinlv    l...    ,vi...t...l.        rn.l..nl.t..lly.  thr    .hv.h.) ..t    ..t     th..    typhoi.) 

,.nlat-..nu.nt   of  th.-   -ph-n    -ImihI-    In    .n.-t     intitnat..   nlati....    with    the 

l,,..ilh.<  ..(•  KlM.fth  an.l  it-  t..Nin-,      In  f^v..,-  of  thi-  vi..w,  iKihap..  .>  llw 
.,l„,o-t   ..on-tant    pn-.n...  ..f  l-a.-iUi  in    th-   -ph-n   Mft.r  .hath,  Mtt.l   al- 

,!,..   -n,.,...s>fnl  .Kiaon-ti-atiot,  of  th.in  l.y  pnti-tntv  of  th,.   ^pl-nt  'Innn^: 
lif,.    t..  wlii.h   i-..f..i-..n.-..  has  altva.ly   1.'<mi   itia'h'. 

Tiu.  sph...!..  t.nnof.  as  ha.-  l......  s.i.i.  .-  a  tnanif.Mation  -f  tl...  I.l-nh' 

-f,.n.  .,f  tl...  .liMa-...     N'  itlu,-  th..  tim..  n..r  th.'  a..-,-,.,.  ..f  its  .l.v.l.,p.n..nt 

ap,v.a.v  ...  l..aranv  nhiti....  t..  tl...  s..v..rity  or  tl...  .•ha.a..t..r  of  tl...  f..l.tih' 

...„„■...       Mafk...l  "..nlaft:.n...nt  .,f  llw  -phvt,   i>  ..l-Mfv...!   ..v.n  .'arly    tn 
,h,,  „,il.l..-t  ..a.-..s  ..f  tvpl„.i.l  f,.v..r  with  a  -h..ft  ■■.■.nitt..nt  ..r  n.t,.fm.tt..nt 
f,.l,ri!.    ....Mfs...    an.!    also  in    th.'    pf.-tt-a.'t.Kl   <'as..s  with    hi-h    h.v.v.      1 

Inv..   ....n..vallv   „l,s..fv...l   .■nlafir..n...nl   of   tl...  -phm  «v..t.   m   .-a-.-  ..f 

tvphoia   f..v..."  aln.oM    nna.t.n.l...lwilh   f.  v.f.      With   th..  ot.M.t  ..t   .-.n- 


SYMI'THMS  AMI  roMi'l.iCATin.XS. 


179 


,1,.^,  ..|i(.(. — iliat     is,   witli    rcdiirtiim     in    the    fever-;— invcilntinn    of    tiie 


spleiii'     tllMi'ir 


llslliillv  l)e<'il!s.       At    tile  e 


if  ti,e   t! 


Hill  or  (hiniiu'  llie 


I  iiiiili   ueik    it    i  •    then    llM  Iniiucr,  ileiiii.il-tl;it)le  in  i';im>  tli:it     |)Ul-lle  MM 
ipnlili:il\   idlirse.       'I'lie  ureale-t  deirree  of  -jileiiie  enl:il;;(nienl  i-  exliiiiilol 


■felierMllv   Ml    llie  mcih 


kI   lip  til  tlie  lieLrinilill''-  iif   tlie  tllil'il   weel 


e~|)eei;illv  |iri itr;icteil  e;i-e<  i-  it  likilv  lu  lie  deti'lled  |..;i  l;iter  |)eliiiil. 
Tlie  time  fur  tlie  <•( iniieeiieeliieMt  iif  (lie  s|)leiiie  swelling-  i-.  IriilM  iMlMtuMlie 
ami  eliiiii'til  kiiuwl'iijre,  (Hi  the  aver:.j.fe  tlie  iiiiilille  ur  the  >e<-i.iiil  half 
cif  ihe  fli~l  week.  Ill  tllel;:st  ilav-iif  the  til>t  \ve(  k  it- ilillii  a!  ileliiiiM- 
slratiiiii  i-  (|iiite  iVeii'ieluly  im— iiilt. 

I'l-einallire    re'illetiiill    in    the    -i/e  nf  the    elllarired  -iileeM    dlllillj;    llie 


fehrile   stajre    i>  e\ee|iliiiiial.       1  1 
eiiiiditiiiii-,  as    has  lucn  iiieiill'iiiei 


1-    tieiierailv  iieeiir-    'Hi!  '   Miulei'  --lieeial 
I;    ill    (Miiiieelidli   with    |inifllse    lieirni-- 

Di 


Miiw   and    ilt:         al-n  alter   (-|ieeiall\    |ircitiise  diarrliea.       lMinii<r 


the    -ta''e  (if  st(    ,,    < 


iir\es   iiivnliiiinii  nl'  the   siileiiie   tiiiiinr  is  aiiiie  tn 


Ih 


if  tl 


r    lit     tile    -lileell     with 


<|iieMt,    as    iii'<'asi(iiialiv    eaii 

Hilled,    however,   that    sufleniiiji 

si/e,  as    is   peculiar   In   the  staj^^e   iiieiitinM 

mistaken   for  aetiial   diminulinn    in   -i/.. 


I' 

Ik nfiriiied    aiialniiiiealK  .       It    -liniild 


th 


|ireser\'atiiiM   hI    lis 
e«l,    iiiav    elinieallv    he   readilv 


Ahlliirmallv  ]i"iitraeted  |iersisteliee  of  llie  -]ilenie  tIMIliir  iieeiirs  almost 
■lii-ivelv  in  eases  th;  t  nllii  rwise  aUo  |)iir-iie  a  jirotraeted  emirse. 
t,  it   should    he   lioiiie    ill    iiiiiid    that  -o  Imii:  as  the  typhoid 


111  aiiv  even 

-piellie     tlllllor    IS    (l"IMiill--lniiile,     I'le    ul-ea-e     e 


illMot     he    eoM-l(lel'e( 


1    as 

liavili;r  termiiialed.  11. i-  i-  true  even  for  patients  in  whom  llie  fever 
has  already  disippeared.  They  are  ~till  under  the  iiitliieiiee  of  the 
int'eetion,  and  are  threateiuHl  es|ieeially  liy  llie  daiiirer  ot'relaps,.  Also, 
when    the    spleiiii'    tiiiiior    ha-    alreadv    imderirone    involution,    rene-ved 


in-rease    in    its  -y/.v 


is  indiealive  of  the  advent  ot'  a  reenideseenee  or  a 
relai.se,  i.flen  oeenrriiiir  even  hefore  elevation  of'  lempenitiire  has  take., 
plaee.  Mention  of'  the  oeciirreiiee  of  sjjlcnic  inmor  at  an  almormally  early 
|«'riiKl   slionld    not    he   omitted    here.       I    ha\e  oliserved  sevend 


wliieti  enlarireinei 


the    -|ileen   was  wil 


h   lertaintv  demonstr;d)le  eli 


leallv   e\rli 


il-e   the    foni-th    dav  of  the   di-ease.      Splenic    tumors 


mn   as  i-  iri'iierallv 


prohahK    not    so    rare   even    in    the    period  ot'  ineiihat 

assiiMU'd  ;    there   is  not   ofV-n   rea.son   for  examination   at   tlii-   time,   for 

examination    is   undertaken  only  when   eomiilaint   of  local   syin]itoms  is 

mil.!.'. 

!  liiive  heeii  ilhle  in  2  eases  lo  deleniihie  the  presence  "f  enlarirenient  of 


tlie  spleen  diiriiiL'  the  (leriiMl  of  iiieuiiatioi 


The  fn>t  oecurreil   in  a  wnniaii. 


tweiitv-tive   vears  old,  wt.o  cotiiphiiiieil   iine  iiiiimiiiir  of  pain   in 


tlie  left  side 


11  tasteiiiiii:  her  cliil'''  -j   which  had  develoiKMl  diirinj:  the  nifzlil.  and  a  cause 


for  which  wax  four 


t  splenic  tumor,  to  which  theconinieiieenieiit  of 


ce;it  sj: 


mr:^.m- 


■^mZgr-T-A 


WM 


ii^ 


180 


TYrii'iiii  ii:\i:i:. 


ii 


l! 


If 

li: 

>■ 

■m 

;?: 

M 

!'  ■ 

;;,j:;;;;:u::i:i;:'i:ui:.i':::v  ■:;;>. .1.-. i  >>...,..„. .u.,,. 

,1  ruuuin 'a  '^h-M-l^  |.ain  in  .!,.•  l-ll  m,I...      Cm  ..x.MUiK.nnM  !,.■  u.>  toUMd 

f::.;;:;,;nn.v.,-.  .n.i'ui.i..u,  ,.„..„i:,.  ...i  .nnnw  a>.i,.. .,,,. 

l,„vv..v..r,  ;.  .li.tinrtiv    ,.,li.al.l.'.  Irn.l.r   .|.l.inr   t ;r  um.-    |.i.'m.iI.      In    Hu 

:.,.„r f  '.un  ,lnv>  /•l,illi..~s  .,,,,...n.4  l.M-  tin.  firs.  „„,...  ^^,th  th.  .•„„„„.■,„■... 

^Z  .inlvlo  U..- ...s.  of  Kric.!ri.!>   nnnlion.M    in    I,,.-   lM,nnu>   In.ns..   n,.ou 
acute  ^plfnic  inniur.' 

1„  -pit,.  ,,f  111.-  -.iUMnUUr  run-taifV  ..f  .llliU-rMnilt   ..f  ll..'  -pLrll,  its 
,l.,„.,„-t.-atio„   .liMi.^aiv.  M>  1,M-  Imv>,    nnntionr-l,  .an    fn.,uonliv  n..t    i„. 

„n<l.'   .'itluT  fur   M    -iiort    or   l.m^.r   t •.  if  .am.!    la...lnKM-k-   -mlv   an- 

„l,-,TVc.l.      Tin-   i-   M.lHM.l.tit  in  l-art  npun  th.  ta,t  that  .limii-  vari-ms 

,„.,-in.l<  a.i.l   .i.iarn.i.s  tlu.  avr,-:,^..  M/r  of  tlu'   -pl-.u.'  tnn.np  vari.s - 

M.lrn.hlv.  a.i.l  in  part  ..i.on  tl,..  Ih.'t  ..-,„..ialiv  that  .•NM.n.nati.m  lor 
M,l,.ni.'  ;M.la.-...u,nt  in  tl.r  in.livi-lnal  ra-r  i-  att.iuh-l  vvitl.  i.ot  a  l.w 
p.t.oral  ati.l  i.wlivi.h.al  .lilli.Mihi.-.  A  ^vt.rvai  id.a  of  the  >tat,stf<  ,n 
,l,i.o.n>u.ction.MavlM.  ..I.tainr.i  front  tl„.  folloxvn.^^  .-litnaf.  -na.l.  at 
llM,nl.u><ran.l  Lip-i.  .  li'  th.  vr:,r  1  .-S7.  ain.mj:  --<••-.  .-a-s  .n  tl... 
Hamlmrjr  Ho-,.ital,  >i.l.ni.'  tutnor  wa-  .l.inon-t.-at.d  in  IS.,!*— S4..5  per 
,,,,t  •  wa-  palpal.l.'  in  :U.-J  p.T  rruU  :  ami  unrrrtain  or  waiitui-  m  :U(, 
—i:,.':  p..r  .vnt.  Tiii-  .pid.Mii..  \va-  •■hara.t.ri/.-l.  a<  tl..'  anato,,...' 
nl,<i..Tatio,is  >l.ow..l.  l.v   tl...  fr.<,n.'...v   of  la.-,,  -pi,-..!.'  t..n.or-. 

In  L,.ipM...  a.noMj:-  l';'-^'''  .".><-.  ^l'l-'»i''  tun.or  wa.  .l.mon-tral.l..  m 
1, »,-,l _(;«).  1  p.r  .•...It.;  wa<  iinr..rtaiii  or  not  .LinoiiMralil..  m  ..^..-- 
•in  ,;  p,.,.  ,.,.„t  TI...S..  .lata  a.v  ..l.tain-.l  tVo.n  Mati-tir-  ..ov...-i..,^  a  l..n.Hl 
„,.■„„„,,,  ,„a.,  tl.irt....n  v..t..-s  an.l  .•oll....t...l  ly  .litT...vnt  ol.>...-v...>.  1 1... 
„„,„,,..,- of  .•a.-..s  in  wlii-.h  .■Mlai-..n.nt  of  tl,.  -i,l..'..  wa-  nn....-ta.n  or  not 
,K.,no„stral.l..  ap|....i-  .vinarkahlv  lar^r.'  i"  .-nipari-t.  Nv.tl.  tl...  -o.-n.- 
.po,..li..-  Ilan.lm.^  f.LMHv..  A....onlin.ir  to  my  ^..ii-i-al  .■xp..ii.ii.v.  I 
^vonl.l  l...li..v..  that  th.-un-Lont  tl...  .ntir..  ..on.-.,  oi'  tl...  .li^.a...  .nlarir.- 
„„,,„   „f  ,1,,  -pl....n   i-   not  .l..ii.on-,ral.'..   in  f.vni  'JO  ,o  ■>:,  y.v  .rut.  ot 

*  "  \Vm?  r,-ar<l  ..<i«vialh  to   tl,..  .li«i.-,.!ti.- att..ii.linir  ,.xan.i..ation  of 
tl...  -pl.rn  in  -aM.-  of  tvpl.oi.l  t;.v.r,  .!,.■>.■  a.v  .I...  i..  I-avt  to  tl...  si/.,  of 
tl.„  orp.n  at..l  t.,  .1...  ...a.....T   i..  wl.i.-l.  ,t  na-.ts  at  .litlnvnt  ......■<.-.  tl... 

i„,;.,tions  pro....^s,  ati.l   in   pa.'t  to  to,H.un.pl.i..,  ntt.  n  in.l.vi.lual,  Lu'tors, 

.„•  to  ant,.<....l..i,t  or  ass.K.iat..l  l.-sion^  in  a.lia.-....t  o.-ai.s. 

\hov,.    all     it    -l.onl.l    1,..    n.,.ntio,n.,l    a...:.;n    at    this    pin,'.,    that    th.. 
tvphoi.l  spioni..  tninor  i..  p'"-'^''  "1"<-  ""»  ='"='"'  '''>'  •■""^"l<'-^'''''"'"'f-'"''' 

,  YulknidiiHS  Snmmliiiiij  IJ'ii.    \urtr. 


SYMI'I'lMS   .I.V/i   ((iMl'I.KM  loys. 


181 


of"  size.  In  tllc  tlliilillr  "I-  |(.\v;il(l  I'lr  cliil  nf  tile  tirst  Week,  even  at 
tile  l«i;ilillilli;  i>\  llic  ^icui'il  week,  it  i-  ullcii  ilrnioii-tnilili'  iplilv  (ill  |ki- 
<'u~~iiiii  III'  i~  |iMl|iMlilr  liv  tli<i~i'  i'\|M'i't  ill  |ial|i:iti<iii  mi  ilii  |i  iii>|iii-:i|iiiii 
)ii-l  IkIiiw  llir  (ii-imI  Mii'li,  citlii  r  :i>  a  di.-tiiiit  ridiiiil  ur  rallicr  .-liai|» 
hnnlci',  111-  :i~  a  -iii~c  nt'  iii-|)ii  itrnv  iiicrcMM'  in  n-i-taiicc  in  tlic  rtj^inii 
ill  i|iir-ii(iii.  Al~",  Ml  till  li('ii;lit  III' tile  <li>c:i-c,  uiili  wliicli,  a>  aiiat4iniiu 
<ili-ir\atiiin  li:i>  >Ihhmi,  nm^l  iiiaikcil  cnlMi'iiciiriiil  nl'  the  >|ilf(ii  cuin- 
ciilcs,  it  is  |Mi"ililc  in  imt  a  lew  caso  U<  detect  unly  an  increase  in  the 
inteiisitv  and  tlie  extent  nt'  tlie  dlllliess  witlimit  ti'n>t\\iiitli_v  tindings  mi 
|ial|iatiiin. 

In  tile  minority  "l"  ea-is,  at  tlie  l)e<;iniiin>;  or  in  tlic  middle  of  tlie 
second  week,  at  times  even  Munewliat  later,  li.e  splenic  tiimor  a|i]«'ar.s 
distinctly  two  or  tliiee  liiiirer-hreadtlis  IhIow  tlie  co-tal  areli  even  dnrinj^ 
the  res|)iratorv  miil-|Ki-ition.  The  anterior  inleiior  liorder  of  the  spleen 
rarely  extends  mncl.  t';iitlier  downward;  then  prohahly  only  \\  hen 
the  tnmor>  are  ainmrmallv  iarj;e  or  w  lii'n  the  spleen  has  an  im!i>iial 
shape  (<'onsideral)le  loiijrjtndinal  dianietei — tmijrne-shaped),  or,  tinally, 
it'  the  sjileen  is  dis|(la<c<l  ilownward  and  t'oruard,  as  a  rc-iilt  (if  coii- 
jreiiital  oi'  i)ath(il(ij;ic  eoiiditimi*  or  due  to  relaxation  of  the  ligaments 
or  ahiiormal  adhesions  of  the  (h.-pkuiKl  mgan.  In  -neli  ca.-e.-,  in  whi.h 
the  splenic  tumor  can  oe  palpate(l  tliroughmit  a  <'mi-ideral)le  ext  iit, 
on(>  can  ciin\  ince  hin-clt'  tiiat  in  the  hcginiiiiig  and  at  the  heiirjit  oi" 
the  dis,>aM'  the  s|iiceii  i>  nf  tense  cla-tic  con-isteiiey,  while  after  the 
hei  d't  ot  the  di^eax  has  liecn  pa->ed  it  iKcomes  di-tinctiv  sot"ter,  at 
times  to  -ncli  a  degree  tiiat  it  is  le^s  readilv  dci'ion.  tfaMc.  From  tho 
ditl'erential  diagnn-tie  point  of  view  it  is  |ir(il)al>ly  true  that  old  malaiial 
splenic  tnmor-  or  splenic  enlargements  due  to  leukemia  and  p-endo- 
leiikemia  appear  tinner  and  less  ela>tic,  while  enlargements  of  ti.  ,.le<'ii 
indneeil  hy  >e|)tic  processes   fre(piciiily  are  likely  'o  he  softer  from  the 

heginiiing  and  thi'ongl t  their  entire  duration. 

Paljiatl  I  ot'  the  eiilaiged  >pleen  in  the  cunr-e  of  tvphoid  t"ever  is 
attended  with  little  or  no  tenderne--.  At  times,  however,  on  pal])atioii 
a~  Well  as  on  pirciis,-ion,  complaint  is  made  of  a  certain  degree  of  ])ai!i. 
Still  more  rarely  jiaticnt-  cmiiplaii;  s|)(intane(iii-lv,  without  ])ressnre  or 
movement,  of  dull  pain  heiieath  the  left  c.  tal  arch.  More  marked 
tenderness  on  palpation,  or  in  rotation,  on  Heximi,  and  in  Invathing,  is 
indicative  of  special  di>ca»e  of  the  spleen  or  its  immetliate  vicinity, 
including  first  of  all  peris|)leiiitis,  which  inav  even  lie  associat<'<l  \\  itli 
pleiiriti-,    less  commonly   intiircts  and  ahsccsse*. 

\\  itli  regiird  to  s])ecial  anatomic,  to]>(igr:ipliie.  and  individial  intlii- 
eiice~   that    may    render   ditlicnlt   and    jirevent   the  demmistraiion  of  a 


^,,l..„i.-    tn.>M.r,  : i'l.nl.il    .nn.lilion-    plMV  ii.>   >iiim11  -•-;/,    in    tl.i-  .•..iin..- 

ticii.  Am. .11-  tlic  til. I..!-  liial  iini-t  In  .|ii(nll>  l.c  taken  iiii«>  cihi-kIit- 
ali.m,  in.t...ii-Mi  .-|..'.iall.v  i-  I.,  l.c  ni.  iill..nc.l.  A>  ni.tc.iri-ni  in  cans 
of  lv|ili..i.l    t'.vrr   iivn.i-aliv  iii\..i\r-    lii.'    laitir    inli-lin.-,  an.l    (-|.r,ially 

tl„     nci;;lil".fi I    ..f   lii.'    -nat.r    .iiiNalmv    :;ih1    liir    tl-NUiv-    in    UMot 

mark.-.!  .i,-iv.  .  wliiir  lii.   .li-lmti f  lii-'  -mall  inl.-tinf  may  !.<■  .-li^^ht 

or  al.-.ni.  liic  in(iva-r.l  .lillirnliv  in  (Icmoii-Iratiii.:  tiir  r-plmi.'  Iinnor 
nc'ii   l>v  n.i  mean-  aluay-  l.c  d.  |i.ii.li  nt    ii|m.ii   markr<l  ..v.rili-l.iiti..n  o» 

tiif  .■ntiiv  alMl..m.n.       In  a.l.lili..ii  !.>  llu'  j;-i-c.n~  ili-i.nii f  tli<'  mtc- 

tinc,  alinormai  -i/r  an.l  |'..-ili..ii  ..!' a.lja.iiit  [...rtion-  oflM.ucl,  (-|.(rialiy 
til.'  lVr.|n.Mt  t'..iiiiali..u  ..fa  l....|>  .'I'  .■<>1<mi,'  may  n.n^tilnK'  an  ..l>-la(lc  to 
llir  ni-..-nition  ..f  tlic  .nlar-cm;!!!  ..f  llic  -i.l.vn.  N"!  mnly  tlu  iv  arc 
a-.K-iat.'.!  wilii  lli.-.'  .•.iinlili..n-  tii.'  .li-|.ia<vnicnt.-  «{'  tlir  -|.l«rn  already 
nifnii..nc.l,  .iih.  r  .■..M-.nital  or  ar.|iiirf.i.  uc.-asi..naliy  w  iili  tivati.vn  in 
ai.normal  -iluati.m-.  |-;\.ci.li..naliy  al-..  tin'  ..r-an  i-  (livi(Kd  into 
-.•vcnil  in.livi.lii;:!  i>ait.-,  a  -[.ken  uilli  M.-callc^l  Mipcrnnmrrary  -plccns, 
thn-  innrfrrin;:  willi  palpali..!!.  Tlial  t.clmical  >kiii  i-  al-o  a  factor  in 
llu'  cxauiinaii.  ii  in  (|ii(-tion  may  finally  !><■  wortlix  ol    iii<iiti..n. 

1,1  ti»-  laltcr  r.iiiiu<Mi..ii  it  ^ii.iiil.i  lie  ( ^i..'.i,illv  |,<,iiitf.l  out  that  if  tlie 
ilia.niosis  ,.f  M.U.ni.Miuii..r  I-  l.a-cl  ii|...ii  tlif  r.'sull.s  ..f  lK•l•(■u^H..ll  aloiif.  t he 
oxa~>„i.iati..n  >h,mi.i  hr  ma.!.'  1iv.|U.i,tlv  li,nmf:lio.it  a  .vrtani  |.,-n.„  oi  the 
.li^easr  an.l  it  .-Ih'mM  alwavs  vkkl  •i|.|.n.xiM.aI.ly  the  sanu-  nMih.  D.pMul- 
enoe  sIm.i.I.I  hv  no  means  he  pln.-.-.l  U|,..n  ih.'  reMills  ..f  a  Mii-ie  penussion. 
It  i-  ,i,>teNvorthv  that  t..  l!  ■  ^l^il^■.l  eliiiieiaii,  in  eases  m  xvlueli  .m  aeeomit 
of  MieteoriMi,  .'.r  ..ih.T  l...al  e..n.lili  .i,s.  increase.!  limits  ol  the  area  ot 
s,,l..ni.'  .lulii.ss  .•ami..I  he  .h^w.nstratcl.  s|.e.-ial  intensity  ol  the  .hili.ess 
uiU  iii.li..m.  that  the  ..rL-an  i>  ah,i.,rnially  lar.L'e.  'fh..  ^nvatest  si-mlHanee. 
liowever  slmnl.l  he  alla.li.'.l  to  the  results  of  palpatMUi  ot  the  spleen, 
uhi.-h  is  ahvavs  I..  U-  pra.tise.l  himanually  with  the  patient  mi  the  ri^L-ht 
lateral  .leei.hit.is.  in  su.h  a  nm.iner  that  the  left  han.l  Iron,  the  hnnhar 
re-'i-.n  en.leav..rs  t..  push  the  p..steri"r  alHloniinal  wall  n.i.l  the  or-an  m  he 
palp;.te.l  aL-ainst  the  rijrht  han.l,  applied  anteriorly  jnst  heh.«  the  eosta' 
inarLrin. 

Little  is  t.i  l.e  sai.l  elinieally  eoneernin<r  otiier  alVe.'tions  ,,f  the  spl.c  n 
in  the  can-.'  ..f  tvpli.,i,!  f.v.r.  Infarcts  an.',  pn.fus..  lietn..rrlia-e  in  the 
spl.ni.'  ti-Mic  .■.lm..M  aUvay-  .l.i.k'  .lia^ai..si.,  as  .k.  al.-.vss  an.l  r.ipt- 
nr..  ,.f  th.'  spk.n,  whi.li  ...■••nr  with  .Neeclinir  rarity.  'Ilx'  kist-nanuKl 
e..n.liii..ns  aiv  in.li.'at..l  alnm-1  s..l.|v  l.y  synipt..ms  ..f  a.a.t.'  pcritot.itis, 
^^hi.•h  ar....f  -u.h  vark.l  .ti..!..-!.'  si-nili.-im'.'  that  tli..s,.  compH.ations 
will   at    ino-t    Im'   thoii^rlit   -.1'  "Illy    hy    way   ..I'  .v.lnskm.      Tlu'v   i.ii^dit 

I    ..Tn. ,-,l,lii-.ll-klini-.-ll.'    Sni.li.'Il.'     lhi,t«ch.   .\,:-h\r.    Bel     liii. 

■■  S...  :il-..  v-„  Zi...n-..n,  ■■  KliMi-'li-  I!....l.».'l.t..ni:.M,il....  ■•  •  M  .'  .""'"•'.  '""'■ 
\V.,rh..  IS!..;.  N..  47.  Ii  .■..inMnnii.:iti..ii  tlii.t  c-..iil,.ii.>  ..  mi.nl..r  ..t'  s..hiat.lo  t.'.Oii.u-iil 
ami  ili;ii;n..>tii'  -iiixi;.'.-tiMns. 


w^^^:?^mB^^M^m^^^mm^mm^m^m'^ 


SYMrrnMS  .l.V/>   (  (J.\ll'l.l<MI<).\s. 


IK.\ 


in.pst  readily  Iw  Mis|Mrtc<l  if— as  lias  ii..\v  and  ajraiii  i«»n  ol.Mrv.>.l— tli.' 
,.ii>.t  nf  ill.'  jM  riiuiiitic  symptoms  \miv  immiiliaiily  invc.-.l.-.l  l)y  -iiddtii 
X'Vcrr  pain  \»\n\\   tiic  K ft  i-nstal  airli. 

Kv.Mi  on  |....-I-inortciii  .xamiiiati.m  siK-cial  anatomic  lesions  of  the  spleiii<- 
ti.nie  are  oulle  rare.  Arnon-  .'ul  aiitop-ies  at  llaniliur^'  and  l-«ipsic  I 
„l,m.rvd  infants  and  lieniorriia-e  in  I'.'),  alwesses  ni  4.  rnptnre  m  •-',  ami 
fXten^ve  re.ent  iHTJsplenit.s  in  Iti.  The  last-name..  tii.'nre,  jml^rm;:  tn.m 
mv  other  .•xrK'rien.vs.  is  rather  small.  The  statisties  of  ( Jnessm-er  heurni- 
wp,M.  anatoiai,  rhanps  in  the  spleen  'piile  a-re..  svi.l.  my  own.  Amon- 
11.H  autopsies  he  noted  eonsideralile  <li.-eiuse  of  the  spleen  m  !•. 

Changes  in  the  Thyroid  Gland.— .\lili"iit;li  littK'  lias  iieeii 
n  IH.it.Hl  aiiatuinieally  with  re-ard  U>  tli.'  eniiditioii  ..f  the  thyfuid  ^daii.l 

.hiriiij:  the  ..rdiiiary  ( se  .,f  tyidi.ml  liver,  even  le>.-  lia,-  Ikiii  c,I,mtv»-<I 

elinieallv  in  this  cmiieetioii.  Only  in  ex.eptioiial  cases  ate  ciiaiifies 
f,>mid  in  thi-  oro:aii,  and  the-.'  mav  !«■  nf  an  intlammatury  natiiiv  of 
varyint:  inteiiMty,  up  to  termination  in  Ml.-crs>-formati(.ii.    Nevertheless, 

thev  phiy  a  nioi-e  prominent  -■.;/.  as  a  « iplicati.m  ..f  typhoid  fever  tluiu 

of  the  remainiiii;  iiilt'ctioii-  diseases. 

W'allher.'  who  re|>orte.l  several  ca.ses  of  ty|)li(>id  thyroiditis  from  my 
elinie,  was  al.le  to  show  that  anioni:  To  ca.<es  of  acnte  strumitis  and  thyroi- 
ditis colh-ele.l  l.y  lum.  K»  were  trac'eahle  to  Ivphoid  fever— an  mterestiiii,' 
illu.stralion   of  an   ohservation   previously   made 

The  svmptoms  of  typhoid  strumitis  consiM  in  acute  painful 
.■iilaroviiK'iit  of  tlu'  thyroi.l  <rland,  and  alm-.-t  always  of  only  .m.'dialf 
or  of  a  still  smaller  p.u-tion.  Inllammatioii  of  the  entire  trlaiid  ajipiars 
to  lie  cNtreiiiely  ra'e  in  the  cour-c  of  typhoid  lever. 

Just  as  we  were  aide  to  demoiisti-at<'  with  rcLnird  to  intlammation 
of  the  parotid  -lanil,  so  al>o  in  the  <"!«•  of  tli.'  thvroid  jrlan.l,  the 
morl.id  pro.vss  is  i;  .erally  ol.servd  to  terminate  either  in  suppiii-atiun 
(,r  in  involution  of  the  inliammatoiy  |n-o<'es>  without  the  development 
of  an  ahscess.  The  disorder  appears  almost  always  to  pursue  a  favor- 
able cmrse.  as  Liehermeist.'r  has  sliowu,  and  I  have  lieen  aid.'  to  ileter- 
Miiiie  from  [KTsonal  e.xiH'fi.'nce.  Alarminjr  sympt.mis,  atnonfr  which 
dvspn-a  from  compression  and  displa.ynunt  of  the  trachea  may  Ik- 
mentioned,  arc  amonj:  the  rarest  exceptions.  ( iriessin<:cr,  it  is  true, 
m.'iitlons  a  ease  of  death  from  siit1i.eation,  and  Korjru.  lost  a  patient 
l.v  rupture  of  an  ahs.Hs^  of  the   tiiyroid   ■.daiid   into   the  trachea. 

With  pfereiicc  to  the  itiolojry  <d'ty|>lioid  strumitis,  it  is  esi>ociallv  to 
l,e  iH-int.-d  out  that  it  occurs  more  fre(pietitly  in  previously  liyiH-rplastic 
.,rj,niiis,  ami  it  i>  therefore  more  often  se<'ii  in  regions  where  goiter 
prevails,  for  iii.staiiee,  Sw  itzerland. 


mi^mmMjs:^^smmm^ 


f^i'i:- 


m^-' 


•mgitifii 


184  ryriinih  ii:\i:i:. 

'riif  ri'lalivily  t'rfijiii'iil  iMciirnur,-  ot' tli\  nii.lili-  in  >^\\il/iTl:iii'l  Iim.^  Int-ii 
ilcmmi>lnil.Ml  l.v  "llic  ,-I;ili>li«>  nf  (  iin-.-iii-vr  ;iii4  I  .i.licriiK  i.-l.  r.  'I  In  toriii.r 
olwrvfil  lln-  ("(iliailioll  4  liliirs  ill  1  I  •<  :illl(i|.>ii  >.  lln  lull.  1-  ill  1"'  "•'  1^"" 
|>iili<-iit.s,  in  ti  "illi  iil(Sn->.-liiriiiiirKiii.  In  nlli.r  (■..iiiilric-  lli\  miililis  ir> 
far  li'>s  CDniMiiiii  in  aii-.inlanc-t-  « illi  tlif  LTraUr  i:nily  (.1'  'j-nili  r.  Aiiicmj,' 
:!4!l  allIol)^it•.<  in  llaiiilmrL.'  I  failed  tu  hKnivi'  a  >iiii;l.  .  a.-.  .  I'lirlliir,  iluriiiL' 
thf  irreal  iviilmiil  f|iiilciiiir  in  llialcily  1  hIimtv  id  tlif  rnnililii>ri  lull  Iwiit- 
tlurini.'  liti'-  In  l.tii'^ii'  aUo  il  i>  a  ^'ival  raiilx.  r.iplrr  '  liiif  rciMirletl  :{ 
(•a.si>  iif  aliscc^.-  nl'  tlic  lliMoi.l  -laihl  aiiinnir  '■'-'  aiili>|i>ii'>  al  Miinicli. 

It  i-  iiitcii-liiiL'^  tn  mill'  tlial  l/irlilliriiii-'l"a\ii,' •liaii-c  liiK,  Sliiid- 
liiark  anil  \'laclio>,'  ami  MViral  ollni-  iia\r  ili  iiinii-lrati<l  llir  liarilliis 
lit"    KliiTtli    a.-    liii'    iNiitiii;:   airiiit    nl'    tiir    inllaiiiiiialmy    |iriiii>>.        Ill 

(itiiir  iii-taiii<~  till'  uiiliiiaiy  |i\.it;riiii'  niirPi-uriniiii-ni-,  -tri'|itiM li    a, id 

.■.til|ill\li>r(.ni,  lia\r  lift  n  timilil.  I'lltlir  tlir^f  rcllilitiolis  tile  cnllivc 
wiL-i  ut'tfii  III  iiv  inil'av.inililr,  in  -o  far  a-  tin'  coiiilitiiiii  was  a  |.art  niaiii- 
fcstatiiiii  n{'  a  piKial  M'|ili(iiiiia.  Willi  nrani  tu  tiu'  |iiiin<l  wlnii 
ivpiioiil  -tiiiiiiiti>  ur.iir-,  it  a|i|irar>  t<i  niiiwiili'  <-|icriall\  with  llic 
iM'trinnint:  uf  nmvalfM-iiK'i'  m-  tlir  last  wiik-<if  tlic  iixir.  'I  liiii' afc 
liiit  fiu  r(;Mii1s(if  its  iK'cnfiviicf  at  an  failirr  |mii«l  in  tlif  course  ul 
tv|ilniiil    fever. 

GENITO-URINARY  ORGANS. 
The   Urinary  Apparatus.  — Fi ilie  iu-artieal  .-taiiii|ii.iiit.  it 

apiH'ar-  ile>i|-;ilile  tu  ile-erilie  liuw  the  eliailjri-  ill  the  state  uf  llie  lirilie, 
in  s(i  far  a-  tliev  relate  tn  tin  (■(,n^Iitlltillllal  (li>liirlian<'e  umlerlyiiij: 
the  attack  of  tv|ilioiil  fever.  e~ii.cially  to  the  f,  l.rile  state,  anil  to  follow 
tin-  wytli  a  ili-eri|itioii  (il'  the  conilition>  that  are  ittriliiitalile  to  liireet, 
more  profoiinil,  ami  nioiv  iiiile|ienilent  ili  ea>e  of  the  uriiiarv  a|iiianitii>. 
During'  tlic  t'elirilc  stai."'  the  urine  ri-.nilile-  in  many  n^i.ect,-  that 
exiretiHl  in  other  acute  int'eelion-  di-eaM-.  Il-  amount  is  e^cniPilly 
dimini-lied,  e-|ieciallv  dnrintr  the  lirst  three  week>  of  the  di-ca.-i — that 
is,  diiriiiir  the  ordinarv  duration  of  the  fever.  In  spite  of  ahiindaiit 
administnitioii  of  tliiid.  this  diminniioM  in  the  amount  of  urine  alinoM 
•always  ueciiiv.  natiir.illy  with  vari'tioii-  in  accordame  with  the  seventy 
of  the  attack,  and  e-iiecially  in  accorianee  with  the  intensity  and  the 
duration    <>f  tile   fever. 

In  the  stap'  of  -tee|i  curves  the  amount  of  urine  i-  treiundly  a<r:iiii 
increa-ed,  letiirninir  t  i  the  iihy-iolo.jie  even  a>  early  as  the  licixinniny 
afehrile     pcrioil.        -Vii    iiiinsiial     increa-e     in     the     >ccretion    of    urine 

1  ■    Hi,.  (■,.n.|,li,aii..n.„  ,1,-  .\l..l.iii.ii.:illy|,liu-,      .1/ /■    ""■/    l|-...-A  .   IH'.lli. 

s    i;l„-r  ■!:'•  .\,i:.,l'.<ll'     /,,■  Stramift.^.  vU-  .    I!:l-I>-,    Is'.i'J,   s,.l|ii,ii,in. 

'  ■■('.. iitrili.  ••i  I  .111.1. ■  .1.-  tliyn.i.lil.-  intact.. '    An-/,.  <j.n.,  .Inly,   IWllj. 

•   \V,.;,.    kin,.    \i:.rh..    r.MHl,    N...    liH. 


wii^^j^mEta^m^^^mMrjm^jmm^mma 


SYMIToMs  .\.\i>  (  n.Mi'i.li    [Tioss. 


IH.: 


•  Iiiiiiif^  llic'  |iru;jr(-^  i>\  ii.ii\  alc-iriii-r  i-  1)\  till  irir:iii->  a  rail'  iiiaiiilc-- 
I  ilicifi,  -11  thai  llic  ariioiiMt  iiiav  iiacli  lii.niMi  .■.ciii.  ami  iiiuit  in  |\mii|\- 
liiiir  liiiiii-~.      The  iiiiiif    i-  till  II  iriiiaikaliK    ii;.'-|,i,  a~  ili  ar  a^  ualir,  aiiil 

nl'r\iiii|in;:l\-    |n\\     .-IHTilir  ;rt-.|\  ily ijliWII     In    I  <  M  I  J.         {{a  ri|  \  ,    .,  nil     thl'll 

i'-|iiiiaii\-  ill  ini'\iiii»  imThim-.  wuiium  a>  will  a-  ii 


III,  ilii^  iHilviina  iiiav 


III-  a|i|iarriil  a-  rar 


Iv  a-  ll 


r  I  itn-  iiipriiiiii 


it'  1  III'  ri'lii'jii'  |ii'i'|iii|. 


N\  itii    till'  I'l'iiiaiiuii  ill  li,,    aiiiiiiint  nf 


iliiiiiii'  till-  tilii'ilf  >t, 


!>:'■, 


Ilir  I'liiiaiiiiiij,'  iiiaiiilc-Iatiiiii-  ut'  i intratimi   arr   |iii-.iiit  :   aliiiuriiialh 


ilark    I'lili.r, 


triiirfallv    larar,   nr    ui 


ill    a    -.I'll 


iini'^t.  wliiili    tinn    i'iiii>i>t-. 


|iiiiiri|ially  nf  iiiali-  ami  iiiii-  ariil.  Nut  ranly  tlir  ilark  n.lor  i|ur-  imt 
iiin'i-|Miiiil  iiilinly  with  ilir  -|Hiilir  j^niviiv.  'I'lir  lulur  iiia\  lir  iiitin- 
-iliril  liy  tlir  |in'M'iii'r  in  tlir  urine  in  rmi-iilri-alili'  aiiKHiiit  nl'  iirinarv 
|iii.''nii'iil~  iitlirr  than  tlir  nrilinars   mii 


I'-.  Ilir-i'  will  III'  ili-i'ii— .III  lirii'riv 
lat.T.  'I'll!'  >|iirilii'  ^.Miivity  i»  alnmst  aKvay-  riPii-iilrraMv  iiici  "isi'ii — 
np  til  |t».;o  anil  almvi';  rarrly  it  ilnlini's  t.i  Kljii.  '|'|i,.  reartimi  nl'tlie 
iiriiii'  fniiii  till'  lii'^riniiiiiir  lit'  the  ili^ra^'  ami  at  the  luiirlil  nf  the  fexir  is 
invarialily  -trm.jrlv  ariil,  iiiili'-.-.  i'-|M'i'ial  I'lUKliii'iii--  are  pri'si'iit.  At  a 
later  stajre  the  aeiiiity  iliniini-lie-,  while  ihiriiii,''  eiiii\ali"-ei'iii'e  the  nriiie 
frei|iieiitly  presents  a  neutral  nr  r\rii  an  alkaline  reartinii. 

Ainiinj,'  the  xiliil  eniistitiieiit-  i if  the  urine,  the  urea  ^hiiiilil  lie  nii'U- 
tiiiiieil  tirst.  The  alnin-t  iii\arialile  ami  markeil  ineivase  in  the  aiiniiiiit 
of  -.i-ea  eliminateil  in  tweiily-fuur  liniirs  thniutrhnut  the  entire  felirile 
periiiil    ha-  alnaily    Keen   nli-erM'il    liv   earlier   writer Xeuliauer    ami 


A.  V.isrel,-  I'rattler.'  I'arke-,'  .Miuehis, 


personal  iiive-.ti;r:ili"ii-^  ilireetiii  t«i  this  jHiiiit  have  \ielileil  tl 
I   ha\r  nut  at  all  rarely  iiliser\iil  ilniihle  the  |ihvsiiiliii.rii'  avi 


II.      A  hirp'  luiiiiUr  of 


le  same  re-iilt. 
initre  aniiiiiiit 


urea,    anil 


now    anil    airaiii    even    nmre    than    this.      The    | 


iriiee.-sis 


ri'spiin>il)le  fur  the  fever  in  eases  .if  typlmiil  fever  exert  ilistinetly  the 
mil  t  iiu|Mirtant  iiillneiiee  iipun  tin-  iiiereascil  eliminatimi  nf  urea.  The 
view    that    the  elevatimi   uf  temperature   almu — that    is,    the    imreased 

heat  uf  the   lHnly-ti-siie^ i-    tu  lie   liiiikiil   ii|)ii!i   as   the  cxeitiii);   factor 

must  he  rejeeteil  at  the  pri  -ent  ilay.  rniliiul)te<lly,  iiien'a.sed  elimina- 
tiuii  ut  iire.i  anil  felirile  ele\atiun  uf  ti'm|M'niture  are  eii-<irilinateil  mani- 
te-tatiiins,  ilepemlent   ii|Hin    the   intlueiiee  of  the  tuxliis  U|(un    tl 


le   eiiurs<' 


III    iiietaltolism. 


In  the  periuil  i<\'  .leferveseenei'  a  reiluetiou  in  the  elimination  of 


urea 


lieu'liw  almost  invarialil 


y,  .'ilthiiiiirh  at  this  lime  it  is  jrenerallv  alnive  tl 


limits    uhserviii  ilurini:   health.       I)urinLr    the    perioil   uf    euiivales. 
the   physiolo;ri(.  amuiiut   eliminatei! 


eeiice 


is  irenenilly  a^^;!!!!   attaimil.      In  a 


.\„i,;f„ 


'  J{nnii/)itrrii(i-/iinir/. 


*  On  Ihf  I'riiir.  ISCO. 


v'-.-'..,J.'i'.1iJ. 


^:-j  y 


ISC, 


ryriiniD  Fhvi:!:. 


„l„.,of  in-taiM-.-  I  l,:,vr,,l,-.iv,..l   (V..i  .lm-in^'  ,.nnvalc«.-cn.T— .■vn 


wli.iv  111.    1.   of  iiMiiri-l.iiiK   111''  p:iiM  ni    iii 


>ll<ll  i;l-.-  lll<l    ll"l    illlVir 


,.,,„„  ,l,al    in  ..tli.r   r:,-,-.   ,.f  tN|,l....l    li^.i— :.   ."..-i-l.  n.l'l-.  lunjr-iim.M- 

,;,in,.,l  innvM-   in   ll,.    .Inni,,;..! f  nn  :,.      Will,    tin-    u:. n-tMntlv 

a-u.u.r.l  ,,r,.^n-.iv  .v.hHlinn  in  lli.  UmIv -«,i-ln,  a  .un.l.Iinn  ll.at 
!,,,,„..„■,  In  nn.l.r  -n.li  .a-.-  "->ll«}  "I  Iik-iImt  invrMijraliun.  ll  Ik.- 
Uti.  Malr.i  i.s  -on,,  u  ,  it.  I-  tlial  .  v,  n  at  th,.  Ini-l.t  ..ftl,..  alta.k  n. 
MV.iv  -..-.all..!  a.Unaini.-  .a-.-,  -n.l.l.n  iv.ln.ti.m  in  ll,.'  ain.mnt  ..t 
,„va  n.avlH,.l.-.rv.'.l,an.l  tliat  tl.i-  manif.  Mati.m  i- .•al.nlat.-.l  t..  nn.l.r 
tl,..  ,,r.,)in..M>  inn.l.  ln...v  -lav.  1  Lav.'  ,,.i-.. nails  n.,t  a-  v.t  n,a.l.. 
>,i.li  an  111,-.  r\ali..n. 

I,iU,.  .1,..  nna,  tl,.'  nii.-  a.i.i  i-  a!-.-  alin.-l  ,n..A.'.|.ti.,nall.v  m.ivaMHl 
i„  ,!,.■  f.l.ril.'  Ma.^.',  an.!  at  tin,.'^  .|nit.'  .■..nM.l..,-:,I.K  .  Tl,..  .lirninati.-n 
,,|-  „,„.  a.i.l  i-aU...liinini-l,..l  a._'ainvvill.  lli.'  .■..inm.n.vin.  nl  "t  •'"n- 
V  ,l.'^.-.n..,  an.l  nlnrn-  t..  lli.'  n..n„al  .luring  tl,.'  I"ii."l  ••!  iv,'.,v.n. 
Tl„.  .viH.il-  l.v  Kn  li.l,-  an.l  Sia.ll.i-  will:  r.-i,nl  t..  tl,.'  |,r.'-.„.'.'  .,1 
l,„,i„    ;„,.!    ivrn-in    an.  lainiliar  an.l  ..li.n   .it.'.l  ;   ( ifi.'-in^.r  aU-,   .'...,- 

.-i,l,.|--  tl,..v  -nl,-tan.'.-  a-  aiin.M -tanll\    |.n'-.'nt. 

Tl,.'  .•l,l..ii.l-.  a-  in    n,anv  ..ll,.,'  a.'„t.'    inf.'.'ti.'n-  .li-.a>.'-.  an'   alua.v^ 
t,,...atlv  .ii-„ini-l,.'.l  .hiii..'.'   tl,.'  f.'l.ril.'   -ta.'.'.  f   in-  na-.'   a-ain  ...n-,.!..-- 

„l,lv  ;vitl,    ll,.'    -nl.-i.l.n.'.'   ..r  tl..'  .li-a-..       H |.i.n'".   "<    •'"!.   \  "P'l. 

iI.m'i    tl,.'.li.„in..ti..n    in   ,.l,l.„i.l- 'i-  .l.']..  ...l.i.t    >..l.'l.v  niK.i,    tl,.-   1.'->.'...^I 
,„„.,„„    „f  -„.li.n..   .•l.l...-i.l    i..i:<-l''l  ^^i'l'    ''"•   ''•'"•■'''•  '"'■'■  '-    ""   '""^"''' 

,..„al.l.        Tl.i-    1,1,.'.. n,.,,    ...'.•ni-   n..u    a-   f.-.-.n-rlv,   alll ;J.    H     hn^ 

1„,,,„„,  ,.„M..n,a,-v  in  .a-.'-..!'  tv  I'l'-i'l  I'V.r  I..  a.ln.i...-t.'r  .■..n.'.i.lrat.'.l 
,.„„n.|,n,.'nt  .'..ntainin.^  a,,  al-nn-la,,.,'  ..l'  -"Vuuu  .'l,l..,',.l  m-l.'a.l  ..I  a 
,li,,,  ..»■  xsal.'fv  -...,,.-.  I-I,.'  .„..•,'  n'.'.'..t  l,v|,.,ll..'-.'-  uitl.  .•-t.nn.'.'  f, 
,,„.  ,,„.i,„,l„„  i„  .'l,l„ri.l-,  l,..w.'V.'r.  al-..  apiMar  vnln.n.l.l.'.  >-  tl.at.  a>  a 
„,„„.,•  „f  fa.'t.  it  w.ml.l   a,,,,.'a,-  u.^'tl.  "LiL'   t"   ni.'l'ftak.' a  n.'W  >tn.iy 

of  ll,.'   .|.i.'-ti..ii.  ,     •  1  ,■ 

Tl,.'  a,,i,.'an,n.v  .-I'  all.nn.ii,  in  tl..'  nrin.'  i"  •■:'^'-  "<   'M-'"-"'  •'■^■'■'"  '■ 
of    ...,u'.ial    in,,..,.-ta,„.'.      Tl..'    ...l.-tan.'..>    f...n..l    '""l-f    ^".1.    .'Mvnm- 
.,.,„.•,.-   an-    kn.Avn    I..    I-.'    x.nn.-all,....,...    an.l    >.'n.n,-l..l,..l.n.      Lv>s 

,,„„n,.,nlv.    an.l    ..niv    ..n.i.-.-   ..rtain    .l.'tinil.'    ......liti....^,  <i-.>    l-r"""' 

,,,,  i,;  ,1,„   „,i„.'.  a-  (i.rl.anlt  was   tl..'  f.t-t    t.,  ,H,int  -nt.      W  .'   >l.all 
fir^t    tak..    ,.].    tlu-   -•..n-i.l.-.-ati.m    ..f    tl..'    .liuiinali-.n    ..f    all.n..„n    that 
o,.,.nr>^  witl,....t    ,,r..f.,nn.i  -li-.-as.-  .,f  tl,.'  ki.in.'vs.  a.t.l  .<  P'.ui-.Hy  -l.'s.tr- 

„at..l  a-  f.'l.ril.'  all..H..in..ria.      WV  -kail  n'tnn,  at    a  -.'parat.'  pla..-   t.,  a 
iM.n-i<k'n,ti..n  ..f  tl,.'  all.mninnria  .liu-  t.,  artnal  n.'|.l,nt,>. 

iM.l.ril.'    all,..i..in.iria    i^   <>xm'  .'f  tl..'    n.or.'    .-..ininMn    luanii.-stati.ms. 
Ar,-.,nlin<:  t.,  n>v  ,'X,...ri..,..'.',  it   -'an  l..'  .U.n.mstrat.'.l  in  Iron,    lo  U.  ''O 


i^^^U 


syMlloMS   AM)   <  OMI'I.K  AJKiys. 


1H7 


iior  cent,  nf  caws  of  ts|iliipi<l  livir.  I  lia\"-  niulicil  tliis  (•iinclii?«iiiii 
t'riiin  tin'  stiiils  111'  a  larj^c  iiiiinlur  of  .a-i"-,  iiic  lii.liii;.',  iiMliirallv,  iiiilil 
:ii  well  as  tnarkcil  ca-t-.  I  ii  a  iiiimiIm  r  nt'  r\lici-i\  i  i  pidi  iiiic-  I  lia\i' 
uli-crvid  the  |ini|Nirliciii  in  lie  lowir;  tia-  in-tainr,  in  llial  at  I  laiiiliiif),' 
ill  |ss(;-l,s,s7  oiiIn  in. 7  |Kr  ciiii.  of  ilic  i'a^<»  i\liiliiif<l  tdirili'  all)(i- 
Miiiiiiria. 

Tin-  latter  liijiirfu  arc  a|iiiriixiiiiiitc(l  also  liv  my  l,<i|K.i(' ^talistil•s,  in  wliii'li 
till'  |iro|K)rliiiii  vvM.s  I1.;!|ht  cfiil.  ( tii  tin-  otlnr  haml,  llic  >tut('rn('Ml  of 
( Iiiliicr,'  tliat  allminiiiuria  is  lonstaiil  ilurin;:  ly|ilioi(l  t'cvtr.  is  (lilficiilt  ot' 
t\|ilaiiatioii.  ( )tlnT  olisiTviTs  naiiu' lii^rliiT  ti:.'iiris  than  I  dn,  a.-,  for  iii^tainf. 
Miircliisoii.'  «lio  oliwrvcil  allainiiimria  in  '■>'■'<  <if  '_'■"<'_'  raxs  -o"J.l.'t)  per  cent. 
This  is  assiircilv  not  tlif  rule  ;  |M)^silily  il  may  lie  i'X|pliialilr  hy  tlic  fait  tlial 
Miiri'liison's  siati.-tii's  arc  liasi'il  n|>on  a  collti'tion  of  smaller  iinliv  iiliial  ilata 
I  personal    ohservation    ami  that  of  >ix  other  w  rilers  .  ami    thai  >everc   eascH 

is|H-eially  were   taken    iiil nsiileraliiHi.       Il    i>   Inir    aUo  that   Weil  '   ami 

( iriessiiiL'er  irivc  hiirh  eoniparativ  c  |Kr(entaL.'e>.  Thi'  lallir  iHlieve?  that 
fi'lirile  allmminiiria  oeenrreil   in   one-thini   of  his  eases. 

Allnimin  was  present  at  >onic  stai'c  of  the  ilisease  in  (iUl  of  .si'll  cases 
(71  |MT  cent.  I  treateil  at  the  .lolnis  Hopkins  llo.-pital  <  »sh  r  '  i.  This 
im-liiiles  the  castas  in  which  the  allininin  was  con>iileralilc  in  amoniit.  as  well 
as  those  in  which  the  t'aintest  |H)S<il)le  trace  of  allainiin  was  prcx'Mt. 

Tile   aniiiimt    ot'  ailiMiniii    c  iiniinateil  \afic-  fruiii    trace-    i  ■  niiMlcrate 

aiinmiits.       Tlic  prc-cmc  ot'  a  iatiic  ai ml    -IhimIiI   aluay-  lead  to  im.rc 

careful  i\\aiiiiiiatioii  fir  the  |irc-ciicc  of  iirufuiiiiil  ili~ca-c  of  the  kiiltie\>, 
wliidi  can  altnost  always  he  (Iciniiiistratoi  iinilcr  -iicii  ciinditioii-.  It 
cat!  lie  >tate<l  ddinilcly  lliat  mily  the  more  -cmic  and  llic  >everc-t 
cases  exliiliit  allinininiifia.  Tlic  cunditinii  is  tlicicforc  oni'  tiiat  makes 
the  ]iri>!.niii>is  di-tinctiv  niorc  tjfavc,  and  the  mure  so  tlu'  earlier  it 
apiK'ars,  the  Imijrcr  it  pclNi>N,  and  the  ^'rcatiT  the  anmntit  of  allinmin 
eliminate!.  Of  .'!'.•:>  ca«es  of  fchrile  alliuininni  ia  that  1  have  collected, 
death  (icciirred  in  Hl7 — 27. '2  |mt  cent. — a  nmrtality  fully  three  times 
the   normal. 

As  the  iM'riiMJ  for  the  heiriiinin;^  of  allnimitniria  I  wuiild  desjirnate 
the  end  of  the  (list  and  the  entire  -ccoiid  week,  in  contnidistilU'tion 
from  other  writers  (Mnrelii--un  and  l'in|.'cr).  who  have  never  ohservcil 
il  lieforc  the  sixtiH'nth  day,  and  most  frci|ncntl\  lietwciii  this  timi'  ai'd 
the  twenty-fifth  day  of  the  disease  ;  its  aihcnt,  however,  is  also  (|nite 
fre(|iiciit  to  the  end  of  the  thin!  week,  and  ii]miii  thi~  |Miint  I  am  in 
ai;reemelit  with  Weil.  Its  neciirrenee  hccomes  less  fretpicnt  al'ter  the 
third  week  ;  it  has,  however,  come  under  my  ohservation  even  (piitf! 
late,  np  to  the  fi>rty-<'ijrlith  day  of  the  di.-ease.      I  consitier  late  apjK'ar- 

'  /)/,•^  ,/.'v  .«,■,.  mr,l..  Art.  "  .Mlnmiii.arii'. "  '  /-■"•■  rit..  p.  488. 

'  /'//■  f'"Oi"/nfjif  tonf  Thernpif  ih.H  A/n/'On>H'iffypfins.   1883. 
*  Jii/iii.i  ll'f/ikins  If"!'/i.  /{/■/>.,  viil.  \iii.,  p,  4'17. 


11 


w.    ^s^' :'^-(Tm'i  •'>'i^.^^ 


%i^^i^Mmmi^^!Mm!ki^amky:^^'^ME 


',^iv- 


^^riy-y/  ^^"•'■■'  ^--'y^-^yi  ■  ■-:: 


MICROCOPY    RESOIUTION    TEST    CHART 

ANSI  and  ISO  TEST  CHART  No    2 


1.0 


I.I 


1.25 


i- 


*-  illllM   |M 

!r  ilia  11^ 

^    12.0 


1.8 


1-4     IIIIII.6 


_A  /APPLIED  \tsMGE     Inc 

^—l  -'  '■    F.ast    Ma.'i    i'-ett 

~J:  ■-    ■  "es'pf.    New    Tofh  t»h()y        i^;^ 

•-=  'f^l    *e2  -  0300  -  Phor« 

=^  n)   298  -  5989  -  Fo« 


J-  i%^-::^:^^-^,!smf^xt^m^i-:'-'  ■'^:iUi?^t^^z^^y:,^^s('''  ::^i-<-'^f^^:im/^^o^. 


IfSH 


TYI'llnll)  Fi:vi:i! 


Sf>-iv 


lir 


a,,,-,,  of  ;illMin.iiH.m  .-|..riMlly  M„rav,„-,,l.l.-  fmni  tli..  j.rujrMc.stic  i.oint  of 
view.  I  liiivr  oliHTv.d  it  t..  lie  i;.ll(>\\v.l  l.y  .IcMth  in  an  unnMuiUy  lavj,r,. 
nunii.r  of  ,;».-.  In  i>olatr.l  -aM^  1  iiavf  ..hscrvcl  ali...niin  t..  ai.pcar 
in  tiu'  nriiu'  .lunn>:  the  fust  \v,rk,  to  <li^al.|..■al•  in  tlir  .•oni'.-r  of  a  f.w 
•  lavs,  and  tiicn  to  ivai.iHar  in  varvinir  amount  and  for  a  vaiyiiifr  ixriod. 
Sti-iisin--  a-  tlii-  fart  i-  m  itMJf.  I  iiavc  Im.h  inial.lc  to  .■<tal>li>li  any 
relation  l.ctxw.n  it  an.l  otli.r  d.viation.  in  .•oni-<.  and  t.  nnination.  The 
(•hs.Tvation  that  tiu  ali.uiniuufia  is  iii<iiy  to  !.<■  in-iva-.d  or  to  ivapiR'ar 
.;,  Hnfr  ivlai.>cs  and  ncnidcMrii.i-  ha-  been   cnii.iiaM/cd  fiv.iiicntly. 

'he  (hii-ationof  frl)nh'  alhnniiinn-ia  in  thr  in.livi(hial  .as.^  ai.pcai^  to 
,.ov,  ,...nd  aiipfoxiniatciy  with  it^  intensity.  In  tinv.-fonrtlis  of  all 
,,,-.-  it  |,.Tsi-t^  in  my  exiKficn.e,  l.-s  than  twclv  days.  A  duration 
„,,  to  ilinv  w.rio,  cveptionally  al>(.  lonpr,  i>  not  at  all  rare.  Of  f<2 
ea.e-of  f  in-ile  all.nminuria  that  I  have  analx /.d.  I  found  the  diifation 
to  he  from  on.'  to  thiv  -lays  in  •",  eases;  from  four  to  -ix  <lays  in  'J.'.  ; 
from  Mven  to  nine  day-  in  !.'"■;  from  ten  to  twelve  .lays  in  1 'J  ;  from 
thirt..n   to  tw..nty-..n.'  .lays  in  -Jo;   iVom   twenty-two  to  twuty-sevon 

<la\s  in  •"). 

"  Mi<.r.iM'..i.ie  examination   of  the  urinary  se.liment   .liM'los.'>  m  .-ases 
of  \n\vr  t.l.ril.'  alhmniuuria.  in  a.l.lition   t.>  erystalline  structures,  v>\n- 
eiallv  uri.-  a.i.i  and  urates,  isolat.^l  white  hl..o.l-.^.r|uis<.les  an.l  epith.lial 
0.11-  from  th..  m-inarv  passa-.^.,  and  jr.M.erally  a  f.w  hyaline,  oth.rwis,. 
„„el,ant;v.l,    tnh.-.'aM-.      In    tlu'   i,r.s..n.v   of    sli-ht    all.uminuria  th.-ir 
nnmlHT  i^  p'n.i'allv  h.  small   that   th.;-  .-an  h.'  foun.l  <mly  in  the  >edi- 
,„,.nt  ol.taine.1  with"  tlw  ai.l  of  the  .  ..ntrifu-e.      OAvv  '  Mates  that   tuhe- 
,,,M-   wer.'  iMVM.nt    in  iilH   .'f  th.'  S-J!>  eaM>— IT  j.-r  .rnt.  ;  or,  in  otluT 
w.ml-.   (i.-!   l).'r  cent,   of   th.'  .•a.Ms    ^h.-win.L'    aU.umimu-ia    al>o   sh.>wed 
th.'    pn-n.'..  ,,f  tuhe-.a-t-.      Tul.e-.'a.ts  of  .,ther  kind.-,  an.l  espeeiaily 
in.'n.ise   in   the  nmnl.er  of  l<.nk...'yt.s.  with  evi.h'uees  ..f  inereast.l   .les- 
,,uamati.Mi  on  th..   j.art  of  tlu'  ki.ln.ys,  aiv  in.li.'ative  of  m..re  ,)rofouiul 
lesions.      Tn    raiv  .'as.s   tl   ■  alhutnimiria  of  typh.)i.l   fever  may  ])ersist 
..v.n   thnmirhout   .■,,nval.s,.,.n.r  without    havin-  h.rn    r.l'.rahl.'  in   the 
e.mrse..f  the  .li-.'as..  to  n.'i>hrilis.  an.l  it   may  ^ive  ri-.'  t..  a  hmji-e.m- 
tinn.Kl  p...'uliar  form  «\'  alhumimiria,  at  time-  nev.T  wholly  .lisappear- 
intr.  which  v.t  awaits  thon.u^di  anatomic  inv.-ti^'ati.>n. 

I  l,ave  ohsorv.Ml  such  .•as.'s  on  sev.Tul  ...rasions.  hut  have  hitherto  had 
„o  o,,,..rtunitv  f.r  at.at.nni.'  inv,-stiL'ali..n.  s„  that  I  an,  w.th..ut  knowh..i^'e 
as  t..'„eir  nature.  Thev  are  almost  always  .hara.'ten/,...!  hy  the  presen.'e 
of  a  n..rnial  antou.U  ..f  <Kar  urine  of  normal  .-hara.i.T  an.l  ot  n..rn.al 
sn,.eiti,.  .rravitv.  with  a  snuill  ain..unt  ..f  tn..rpholo!.'ie  el.Mu.-nts  :  s.-ar.vly  any 
epithelial  cells  from   the  urinifer.)us  tuhules,  a  small   munher  ut   tube-casts 

•  J.„c.  eit. 


.slM//'/v>.l/X  .l.V/'  <  oMri.DA  rioss. 


18!) 


fxclii.-ivflv  of  tlie  hyaliiK'  variety.  iicviT  any  hmI  hloixl-cellN  ami  al  iiio.-t  a 
few  wliite  riiriiu.-cle.^.  Canliae  iiy|«Tlr(j|iliy  ami  edfiiia  a|i|iarfiilly  iln  nut 
occur,  ami  1  have  likewise  tailed  to  nhi^erve  uremic  inanifestiition^.  In  -ome 
instances  I  have  olwrveil  such  alhuminuria  to  i>er!^iril,  in  a  charaiteri>lic 
nuiuner,  for  ten  or  twelve  year>  after  the  attack  of  typhoid  fever  i  treated  hy 
me),  apparently  without  any  further  injurioi.s  elfect  upon  tlie  healthydookiiijr, 
functionally  capable  individual,  who,  on  account  of  the  risults  of  examination 
of  the  urine,  may  hecoine  temix)rarily  depressed  or  evi'ti  |)ermanently  \\\\w- 
chondriacal — the  only  manifestation  su^'frestive  of  the  existence  of  dise:u>e. 
Ill  isolated  cases  1  have  noted  complete  ilisap|K'araiice  of  this  alhu'uiiiuria, 
even  after  the  lapse  of  years,  with  the  persistent  peculiarity,  it  is  true,  that 
sliirlit  transitorv  turbiility  of  the  urine  developed  on  the  application  of  test.s 
for  albumin  ai'ler  active  bodily  exercise  or  after  the  inirestion  of  strong 
alcoholic  beverafit  -.  I  have  observed  a  similar  form  of  chronic  allmniinuria, 
the  anatomic  basis  tiir  which  has  not  been  clearly  determi  ie<l.  followiui,' 
other  acute  infectious  disea.se.s  also,  es|;)eci!illy  dysentery,  ^'liolera  iiostraa, 
and   necrotic  angina. 

Ill  addition  to  the  more  (•(uniiioii  cliaiifres  in  tlie  state  of  the  urine 
mentioned,  a  niiiiiher  of  less  coniniuii  siihstaiu'cs  aii<l  reactions  ire 
wortliv  of  ineiitioii.  Tlie  iiiiTcase  ol"  iirohiliii  that  ncciiis  in  the  urine, 
and  is  at  times  so  marked  that  the  condition  is  appfo|)riately  desi«iiiattKl 
iirobiliniiria  (Tissier  '),  is  intcrestinj:.  'Ussier  and  otliers  are  inclined  to 
associate  tlic  manifestation  with  iirofoimd  (typlioid)  alterations  in  the 
liver  and  the  biliary  |)assaires.  Accordin-;  to  Tissier,  the  most  markiKl 
itrohilintiria  can  be  found  only  in  severe  cases,  while  that  of  moderate 
grade  will  be  ]ireseiit  in  mild,  but  protnicte<l,  cases,  I  liave  no  ])ersoiial 
experience  in  this  c(Miiiection, 

The  apiieaniiice  of  iiKHler.ite,  and  even  of  considerable,  .iiii  Hints  of 
indican  in  the  urine  is  (piite  fre(iuent,  and  is  an  indication  of  derangement 
in  proteid  digestion  and  absorption.  I  :ini,  however,  by  no  means  of 
the  oiiiiiioii  that  any  direct  relation  exists  between  tlie  amount  and 
duration  of  indiean-eliminatioii  and  tlie  severity  of  the  attack  of  tyjilioid 
fever;  and  I  am  unable  to  attribute  to  it  either  diagnostic  or  sjiecial 
jirognostie  signiticaiice.  I  have  often  observed  a  more  pronoimceil  iiidi- 
can-reaetioii  in  mild  eases  of  ty|ilioid  fever,  es|)ecially  wlien  attended  with 
profuse  diarrlu>a,  or,  conversely,  with  obstinate  consti]iatioii,  than  in 
severe  cases.  It  iienl  sea  reel  y  be  menti(Ui('(l,  in  view  of  what  is  known 
in  geiier.il  in  this  connection,  that  with  the  onset  of  general  jieritonitis 
and  also  of  circumscribed  peritonitis,  particularly  in  eoniiection  with 
typhoid  ]Mrity|>lilitis,  es|)eeially  marked  elimination  of  indii-in  takes 
place. 

I  have  encountered  true  iKMiioglobiniiria  associatni  with  hemoglob- 
ineniia   in   but   2   eases  of  typhoid  fever.      In   one  of  these  it  occurred 

'  7V,,-.sv,   V»rU.  ISUd. 


I 


¥  $ 


190 


rvi'iinih  I  i.vi.n. 


in  tl.r  iniddl.'  of  tlir  .-..mmmI,  Mini  in  tlu' otli.T  at  ilif  l.(ri""i"i-' "'" ''"' 
tliinl,  \Mck.  r.Mlli  <-a-'>  t.Tiiiiiiatril  fatally  with  -Mnplui.,.  ,,f  iiiu-t 
,,r,,t;,iin.l    intuxi, "111011.      KI(Mi|"iTr '     lia>    fcTiitly    niM.rtr.l   a    .-a-.'   ..f 


l„.„iool,.lm.uria   after   n.overy    tfcin   a    m'V.v   attack    ,,f  typhoid   f.vct'. 
|{o<,ur   and  Weill-   unv    the    lir-l    to   .'all   attention  to   the   i.tv^eiiec 
of  inten-,lv  toNie,  |,n,l.aMy  -|.ecitie   Mil.>lanr,-   in  the  urin.' of  patients 

.iilVerinir   tV typhoid    fevr.       L.'pine  and   (  iiierin  have  reported  most 

i-eniarkal.le  ol.>ervation-of  a  -iniilar  eharaei.r.  In  the  li-ht  ofexiMing 
Unouled-e  with  re-ard  to  til.,  pre-.nee  ..f  toxin-  and  antif.xins  in  tlio 
..iivulaiin-  Mood  in  ,-a-,--  of  typhoi.l  fevei.th.-e  oloervalioiis  .-lionld 
stimulate    further   a<'tive    inve-liua  ion. 

h  i-  tinallv  IMMM— ary  at  thi-  pi.iei^  to  ref.r  to  the  dia/o-reaetion  of 
Khrli.Oi  with  the  nvine  in  ,,,-<-  of  t\  plmid  f,.ver.  the  principle-  of  w  hieli 
and  ihenietho,l,.f  elieiliiiL'  it  may  I,,,  pre-nmed  to  he  familiar.  Doiil.tless, 
tin-  important  reaeiioiiean  al«a\-  U-  ol.tain..<l  at  the  height. if  an  attack 
of  tvphoid  f-vir:  it  i-  p.rmancntly  ali-eiit  only  in  the  milder  case-.  it 
i-  al-o  imdonhl.d  that  in  -,a.  iv  .■a-e-.  wiieii  ii,.|,rovement  hc-ins  to  lake 
phiee.  the   reaction    not    rarely  di-ajipcar-,  -o   that    from  ilii-  si^i  favor- 

:,1,1,.  ,rln-ion>   may  he  drawn  at  a  time  when  otli.r  >yniptoms  arc  not 

in.licativc  of  improNcinciit  or  are  im.vrtain  in  thi-  rejrard.  It  is  not<'- 
\v.,rtl.v.  al-o,  that  in  relap-e>  from  typhoid  fev.r  the  diazo-reactioii,  if 
it  ha.l  alr.^adv  disippeared,  ^'cncnilly  return-,  while  it  docs  not  rcai.jx'ar 
when  fever  occnr-  dnriiii:  convale-ccncc  from  typhoid  fever  a-  the  ronlt 
,,f  or^Miiic  .li-tnrhaiice-  <lnc  M  other  caii>cs.  In  all  these  (M.inurtions  a 
certain  .Icirrcc  of  diai:no-ti<'  an<l  projrnostic  value  is  di>liiictly  to  \w. 
attachcl  to  the  rca.'tion.  althoii-h  it  is  not  al.s.,liitc.  Thus,  rarely,  it  is 
true,  severe  and  even  al-o  anatomically  <hiiion>Ii"iMc  ca>cs  of  typhoid 
fever  have  Keen  ol,-erveil  in  which  the  reaction  wa-  conliiiiioiisly 
ai.-ent  owiiii:  to  nndclcrminal.lc  can-c<.  In  ad.lition,  the  ivaction  occurs 
with  .>pc.-ial  fivipicncy,  a!mo-I  invarial.ly,  in  other  fchrile  dis,.ases,  aii-l 
parti.ailarly  -neh  a-  .itVer  dilli.Milty  in  diiVereiitial  diajrno-is,  .'spc.ially 
miliarv  tnl)ereiihwi-  and  llorid  form-  of  pulmonary  tiil)crciilo.-i>,  tyjihiis 
fever. 'certain  varictie-  of  prot'ound  pneiimonia.  malaria,  and,  finally, 
acute  exanthemata,    particularly    nn'a-les. 

The  term  typhoid  hacillnria  or  liactcrinria  ha-  hceii  applied  to  the 
..on.lition  in  which  ly plioid-l.acilli  are  f.nnd  in  the  nrine.  ■^hi^  oc<.iir- 
in  from  "JO  to  -W  per  cent,  of  all  ca-e-.  The  hacilli  may  he  jirc-cnt  in 
-mall  mimiicr-,  or  lhe\  may  occur  in  enorinon-  nniiii>er>,  -o  a-  to  render 
ihe  urine  .li-linctly  tnrhid.  Horton-Smitli  has  laid  -pccial  -tiv-s  on 
the  peculiar  shimmer  uhich  i-  -(cii  when  a  tc-t-tuhe  tilled  with  such 
^,'i,.,r,i;  A ,/.«,  20,  .1:.!,,-..  i>*:'o.  "  itrr.. I.M.I. .  is;n. 


.s)  l//'/'o,l/.N    AM)    <  OMI'l.KMI'i.SS. 


191 


niiiic  i-  liclil  ii|)  ti>  the  lijrlit  :iinl  <r<'iitlv  -luikcii.  In  tlii>  way  tlir  ccii- 
iliiioii  c-AW  iittcii  lie  ]c, fdicird  witliiiiil  ciilluri'-  ;iiiil  witlimit  iiiicriiM'"j)i<' 
rxMiiiiiialinii.  r-ii;illv,  tlic  hacilli  do  not  a|>|H:ir  in  tlic  iiiiiic  iHiiirc  tlic 
tillfciitli   day,  and    tli<y    may    pcisi^l    liir   a   vMiial>lc   Iciiuili    "f  liiiir — 

(•Veil    till'   iiMiiiili- iir   vcar-  al'ln iivali-i'i>iii-f  c-cvcii   year*   in   tlic  ca^c 

rr|Mifl(d  liv  'N'unnL^').  I'lic  i-c(ci<:nitii)n  of  lliis  cDnditiuii  i~  rvcn  nf 
Miiii'c  ini|M>rtancf  iVoni  the  li\  picnic  >tand|iciiiit  tiian  frinn  tiif  tliat:nii-tic. 
A  patient  voidin;,'  -iicli  mini'  is  a  miuicc  of  cim-tant  daii;2if  I"  all  tlm-i' 
alxiiit    liini. 

A— ociatt-d  with  the  iiacillnfia  i-  iViiincntly  a  niixlcratr  m-  even  an 
(■\tri  iiic  iri'adc  III'  pviiria.  It  is  nut  inK.iiniMinn  tin- tlic  nrinr  nf  typlmid 
palicnt>,  c>p'>ciall\-  it'  alhnniiniii'ia  lie  prc-ciit,  t"  ("ntain  a  few  pn— cclU. 
It',  liii'Acvi'i',  till'  |>u>  i-  cmi^idcralilc  in  aiiinmit,  mic  slmuld  al\vay«  ^ll  — 
pc.t  llic  pn-ciiic  lit'  a  ty|)liiiidal  liacillinia.  If,  in  additimi  In  the  pii-, 
the  patient  ciiiiiplain>  ul'  >li<;lit  |iain  in  jia-^inj:  the  urine  and  -liulil 
t're(pieiie\-  ut'  inietiiritinii,  it  is  |)riilial>le  that  a  mild  ^rade  uf  eystiti> 
cxi-ls,  wliieli  iiiav  |)a~>  into  a  nine  -evei'e  lin-iii  ur  even  U'eume  elinmiv-. 
Thus,  nil  hard-and-tiist  line  can  he  drawn  hctweeii  liaeteriiiria  and 
ev>titi<.      A|)pai'entlv,    Imwever,    mei-e   pre-eiiee   ut'  the   liaetei'ia    in   the 

hladder    is    imt    >ntHeient    U\   cause   cystitis.      I  lurtnn-Smith    i clnde> 

that  "  the  hacillnria  is  due  to  infection  of  the  urine  liy  a  sti'ay  ty|)lioid- 
liaci!l!i~,  excreted  liy  the  kidneys  from  the  MoimI,  and  it>  immediate 
iniiltiplieation  in  the  lilailder-iirinc.  If,  in  addition,  the  Madder-walls 
have  IxH'ii  in  anv  way  damajrc*!,  then  true  Ivplmidal  cy-titis  tiillows." 

Nephritis.— Kmiihasis  has  already  heen  placed  upon  tiie  fact  that 
fehrile  alhiimiiinria  cannot  he  sharply  ditferentiated  from  tlie  nephritis 
not  nirclv  atti'iidiiiji  tvphoid  fever,  anil,  as  it  a|)pear>,  etiolojrically 
related  to  this  disease.  Kaeli  may  iindoiihtedly  |iass  over  into  the  other, 
and  thev  ai'e  attrihiltahle  in  pait  to  the  same  cause,  namely,  the  action 
of  to.xiiis.  The  nciihritis  irencl'ally  occurs  in  the  form  of  acute  pareii- 
elivmatons  intlammation,  in  jiart  licmorrhafxi'',  in  purt  non-hemorrhajrie. 
The  nephritis  ircnerally  o'curs  at  the  iieijrht  of  the  di-ca^e.  hctiire  the 
end  of  the  third  week  ;  and  it  is  iiiucli  !ess  common  at  a  later  jicriod. 
I  have,  however,  ohserved  it  appear  on  the  thirtieth  day,  and  in  one 
inst:iii<'c  even  diiriiiix  convaleseence.  ( 'ases  ot'  the  latter  variety  are 
then  likely  to  he  prolontred  for  some  time.  Of  -Vl  case>,  I  noted  the 
a|)pearance  of  ni'iihritis  before  the  end  of  the  third  week  in  IS.  In 
■J  I'ascs  the  onset  of  the  complication  was  placed  respi'ctively  at  the 
lieiriniiinir  :iii<l   the   middle   of  the   first  week. 

Ajre  and  se.x  exhihit  little  that  is  |K>ciiliar,  although  it  apjjcars  to  me 
'  ./../,»,<  Il..pl<,„s  }l...p.  /{,'/>..  vi.l.  viii. 


l!f. 


TVI'llntli  Fivr.n. 


tliat  111' •!  arc  iittackril  -uii.rw  liat  iimrc  tVr(|ii(iilly  tliaii  woincn.  ami  in 
till-  (■,,,  itii.n  it  i-  |)|-iil)alilr  tliat  the  mmlr  nt'  lil'r.  i-|)ccially  alcolidl- 
i-iii.  i)la\  -  a  part.  <  )t'  S  I  la-c-  of  iirpliriti-  in  adult-  (  l,(i|i>i''  and  liani- 
Imri.''  -tali>ti«-i,  ■>[  ("•ruri-rd  in  niali-.  'I'lii'  |iriiiMii-tinn  i-  iiiiht  -irikiiiir 
in  till'  I,ii|i-ir  -lali-tir^  ainnc,  wIicit  it'  "i.".  caH-  nt' iu|>iil  ili.-,  11  wtrc  in 
nialo.  In  cliiliifcn,  |iarti<Miiarl_v  dnriiiir  tlic  caily  ycais  ot'  lili'.  I  liavc 
oliMTvcil  nc|(liriti~  in  Iput  '1  caM-.  Anidii^f  adnll>  no  -|i<'iial  [indi— 
|)o-itinii  with  ivuaf<l  tn  aj:*'  aiijicai--  tn  cxi.-t.  Dnrin;:  tlii-  piridd  llic 
trc'inrncv  ..t  in  iiiiriti~  is  alxiul  tlw  .sinic  as  tliat  ef  die  l>I■^■dis|l(l^iti<ln  of 
vaiion-  aui>  to  t\|>iMii«l  (ixir  i:cn<raliy.  ( )i'  •_'">  ca-fs  (if  nc])liritis,  ."> 
\\^■\•^•  under  -ixtri'ii  scat'-  of  aL'i' ;  11  lictWfin  sixtfcn  and  twenty-five 
years  inclusive;  S  lictween  twenty-six  and  tliiily-five  year- ;  1  lielwecu 
tliirtv-six  and  firtv-fuc  years  ;  1  between  forty— ix  and  tifly-tiv.' years  ; 
1  atiovc  tifty-fi\c  years. 

.Nuiiieron-  ;;(iicral  statcnieiits  liavc  Keen  made  willi  rejrard  to  tlio 
niaero-eopie  anatomy  of  typlioid  nepliritis,  hut  relatively  few  with 
rcLnird  to  the  liner  alterations.  15e^ides  tindiuL's  -imilar  to  those  atteiid- 
inir  aeiite  intlammalory  le-jons  of  the  kidney-,  which  arc  occasionally 
ohserved  in  association  with  other  intec'ious  diseases,  nninerous  ob- 
servers have  reported  cases  pursuiiiLT  an  cxtremi'ly  pernicious  cour>e  in 
which  microsei.pic  exaniinatioii  is  said  not  to  ha\c  diselo-ed  any  essen- 
tial lii-iolot;ic  alterations  whatever.  Tliesi  oh-ervatims,  it  is  true,  wetv 
made  at  an  earlier  period,  and,  if  repeated  with  the  aid  of  modern 
method.-,  tliev  niijrlit  i)erliai>s  yield  more  sat'sfactory  results.  An 
atttinpt  ha-  heen  made  to  separate  from  the  ordinary  I'ases  of  typhoid 
nephritis  certain  varieties  that  arc  charactirized  by  t!ie  ajipearance 
especiallv  earlv  and  in  intense  dejrree  of  the  renal  manifestations,  and 
bv  the  unusual  duration  of  the  same.  Tlie.-c  may,  in  i.iet,  so  thor- 
oii>;lilv  dominate  the  entire  clinical  picture  that  some  I'rench  writers 
have   devised    the   special   desitrnation    ncpliroty|)lioid    for   -uch   eases. 

Aiiioiiir  the  tirst  of  the  ea.se.s  of  this  character  in  the  literature  are  '_'  hy 
Inimerniaiiii,'  in  wliiili  nephritis.  (Kriirriiiir  at  the  lieitrlit  of  the  disease  an<l 
aecoiiipaiiied  by  iireiuie  iiianife.stations.  led  to  a  fatal  terniiiiiition.  The  iirst 
to  describe  the  eoiidition  as  a  special  disiinler  was  (iubler,'  and  he  was  fol- 
lowed by  LeLToux  an<i  Haiiot  '  with  statisti<'al  re|Mirts,  and  Hobiii.  a  pupil  <>f 
(iiibler's,  who  completed  the  description  of  his  teacher  and  proiKised  the 
(Icsiirnation  ■■  neplirotyphoid.""  Aiiiat  '  then  elaborated  the  schematic  liic.i- 
tatioiis  and  descriptioii  of  this  form  of  disea.se  to  a  relined  dej/n-e,  nial  even 
believed  that   it   ]ire<.iitcd  special  anatomic  conditions,  considerable  eiilarfre- 

>  .J„lin-sl,rn,-ht  il.-r  M,;lirhl.       Jhf/irlhn,,,,/'^    ll„ r./n-.-pHnls  :ii    linsrl.    IST'J. 
»  I,..r    ,-',l 

^  ■■  (ll.siTviit.  cialtniininarii'  dans  In  fiiArr  t\lili..'    Arrh.  ;ii'n.  ,lr  luiil..   IKTO. 
•  "  Sur  la  iii'vrc  tjjili.  t'li  forme  renalc,'    T/iisr.  I'ari-.  IbTH. 


I 


M'.U/'Vo.U.S'  .l.\7»   cnMl-l  I'ATIny 


193 


t  of  tlif  kiilncv,  wiili  cviiliiicfs  of  iuiiif  iiitfr.-tiliiil  iiiHiiiiiniaticiii.  isiie- 


ciiillv  of  llu'  iiircii'ul  .-Irmiiir 


('h;iriicli-ri/.fi 


IV  il>  iiitfriM'lv 


lit'    llllMllllill.    uitll    II>llll('t'liU> 


tli.'ir  ilcir 


»Micralli)li-|inHii'rts. 
rciii;irk;il)lv  liiirli  ti'vcr.  «illi 
till'  ii-^ii;il  ;il)ili>Miiii;il  >\Mi|)tiiii 
Kus.-iiiuill  '  was  uiic  ut'  ti 
Guliler-Kuliiii  ly |H'  of  cliM'iix', 
it  ils  |)ro|i('r  dcirrtc  of  im|M>rlaiirc. 


t*. 

Ar, 

oiililij;  t 

1}  Am 

Mo( 

'ly 

■olor  am 

I  the 

IuIk 

-ca? 

l>.  Ill 1 

-(■or|ii 

1m 

y. 

itioii  lilt 

rv   i? 

rar 

irofouiii 

slllp( 

1>  o 

t.v 

|illoiil   t'«' 

VI  r. 

If    t 

l>t 
wit 

ill  (an 
li  his  (MIS 

iaii\ 

Imt 

t ar 

111,  lliv  uriiii'  i>  iiiv  ai'ialily 
ircsiiHC  of  liir^'e  ainouiits 
silc-,  I'liilliclial  I'clls  and 
said  lo  he  from  tlu'  oiil.-fl 
r,  Imt  uitll  an  alisi'iicc  of 


to  (lirrcl  atlfiitioii   to  the 
y  iHiictration  altrilmti'il  to 
Tlif  o  cases   iiiion  uhicli    his   iiaiicr  was 


liasfd  txhiliitiMl   liy  no  nicaiis  <'om)ilft('  ai:rcfiii('iit,  and   tlicrctorc  cannot  he 
uscil  in  sii|i|Kirt  of  tlu'  doctriiie  of  a  s|ifi'ial    t'oiiii   of  iitplirotyiihoid   in   the 


sense  of  the  French  cliniciai 


I' 


Vrsonally,  I  am  ut  the  oiiiniun  that  acute  iiafeiichyiiiatuii*  iicjilifitis 


II    attack    (if 


a|)|)earin;r   earl\'   ami    inir-iiiiio-  a    severe   ciiiirse    (liiniii^r   a 

ty|ili(ii(l  fever  siinilld   lie  cmisidtred  as  a  |iaiticiilarly  -.eiiuiis  (icciirreiice, 


'I'll. 


■re  is,  liiiwever,  nu  reason   liir  tlic   reciiiriiitimi   of  a  distinct   varietv 


(if  neiiiiriity|i 


till 


I  r  Inr  tlie  se;ii 


;niticiii  of  this  fmiii  utlier,  milder  fuiii 


if  iie|iliiitis,  iif  sliurtei'  diiiiition,  <:cciiiTiii<j  in   the  cmirse  uf  ur  toward 


tlie  end  ot'  the  diseas 


l"he  differences  and   tlie  contnists  are  here  licit 


sh 


ii'p  as 


listiiicti 


i>  theiirctically  lielieNcd.      On  the  c(intr.iry,  it'  a   series  of 

Tl 


ve  cases  are  ciiiiiiiai 


cd,  a  ttnidiial  traiisitiuii  will  he  note* 


le 


urine  cnntaiiis  a  laiy,.  aniduiit  of  alhiiniiii,  with  mimerdiis  hyaline,  irraii- 

i  coii>ideral)l(;  aiiKiunt   (if  hlood,  and 


iilar,  ail' 


id  e|>itlielial  tiihe-easts  and 


marke(l  alidumiiial 


the  di-ease  in  other  respects  pursues  the  typical  cuiitve  of  typlmid,  with 
-ymptdins  ;   and  these  facts   must    he  empiiasi/.ed   as 

litiiiii   exclusive   of  both 
1 


opjKised   til   the  assumptiiiii  of  a   sepanite  cuik 

typhoid  and  nephritis.  Excessive  slnjiiir  or  other  uiiusual  iierviiu 
maiiifestatiiiiis  are,  further,  liy  lui  iiieans  always  associated  with  such 
pnifiiiiiid  alteration  in  the  conditiuu  of  the  urine.  There  is  even  no 
constant   association   of  liijrh   fever   with    |iriifouud    lu'iiliritis. 

With   reiijard  to  the  fre()nency  of  true  ty]ihoi(i  uepliritis,   if   it  1h> 
ditfereiitiated  as  sharply  as   imssihle  froiii  feliiiie  allinminuria,  it  will  he 


found,  as   has  been   said,  to  be  not   at  all  la 


h 


n   mv  exiierieuce  tlic 


till 


condition  occurs  in  scarcely  1  ])er  cent,  of  the  cases.      The  pro)j;iiiisis  of 
typhoid    nephritis  is   jTave,  and 


1  on  this  iMiint    it   must   be  admitted  that 


the    r  reuch    investij.fators 


1 

irrect,  but   til 


not    so    because    the 


orir-anism  is  especiallv  atfected  by  the  severity  of  the  disease  of  the  kid- 
neys, but  rather  because  the  occurrence  of  severe,  especially  heiiiorrhajiic, 
ne|)hritis   is  one  of  the   local   symptoms  of  nnnsually  profound  ifcneral 


uitoxicatioii. 


All 


most  half  ot' all  patients  with  tvpiioid  nephritis  die.     Ii 


this  respect  my  experience 


at   H 


imiiui'ir,  where 


I  observeil  a   mortalitv 


'  Homlnir!:;pr,  lirrlin.  Uhi.    Itc.r/i.,  18H1,  No,.  !.'(),  21,  and  li2  i  .\littli.'ilurit;eii  aus 
dcr  Kiis-iiunirsclu'M  Kliiiikj. 


Ml 


■m\  m 


w  ■  m 


I'.tl 


Tvniniit  I  i:\ii:. 


,,f  :,(i  |MT  (Till.,  .litV.r-   hiilr   imiii    ih.ii    ill 

,,|i,,i,l  r,.v,.r  ;,i    th.'  .loliii-    Iln|.kiii-    llM-|,iial,'  llmv 


l..i|p-ic,  wiili  I  I.  I  1"  r  <■'  lit. 
Iln|.kiii-  llM-|,iial,'  lliiiv 
•_'l.     (  >r  iIk-c  J  I,  7  ili.d 


uriv.lrfmilr  r\  i.  Iciwc- ,  ,f  all  ariit,- uciiluii  i-  in 
_..;;;;  .„.|- ,.,iil.  It.aih  .M-.iir-.  ,  iilici— an.l  llii-  i-  tli''  iihiit  ri.niiiioii — 
.„„i,l  -V  in,,|nin,  .,f  1,1.-1  |,p.t;.iiu.l  unirril  iiiloxiralioli,  -r  uilli  ill.'  -n|"r- 
v,,,.i,.n  ,.f  vaii-n-  .■oiiil-lirali...,-.       In  ■.  nf  llic  7  .mh  -  almv.^  inHilioi,,,!, 

,l,..|lli  „a-  .111.'  I"  |,.  rf..i-ali.m.       In   my  ,  sim  li,- ■  a.lnal  iin  i,,ia  .Irs  ,|.  .|.- 

I, ,nin..nh.       1   \r.i\>-  in  l.nl    1    in-tan.-.'  .  .1  ,-,rv.-.l  .l.all.  t '.■nr  Ir 

„,,,„•„.     Tlii'  ua-  in  a  N.mn^  man,  in  tl,.'  lii'-l  IkiH'  '.I'  ll"   -' I  ^^'"l^  "'' 

.,„  atta.'U  nf  ivplini.!  f.'v.  r,  ulm  .l.'V.ln,,,-.!  rn,iviil-i..n-   an.l    .'.mia,  atur 

'.v,„,,t -..fl'ir iT!,a-i.-  ii.'|.ln-iti-  Iki.I     NiM..l  f..r:i  f.'"  .la.v- -nlv.      In 

.;,l,li,i,,„„,,l„,, ,,-,.-.,(■  linmrrmann  tlial  l..!..!!- in  tlii- .al.'-.n  ,  n  I.  nn.'.' 
l|,„nl.l  I..'  ina.l,'  ...  .li.'  ^'V..,  nf  M ni'.'lii~..n.  A  .'.-  .'f  i;.'!-'.  an.l 
(ian.-li.T.-'  t.nninatin^  in  i',r,.v ,  n  .  a,.,H'ar-  .i..t  t..  Ih'I..:,^  ni  tin-  ^P.n;., 
■l-l,,,  ,iuraii..ii  ..f  .-a-.-  ..f  tvi.lL.i.l  n.-pliriii-  in  uln.-li  .'..mi-l.-to 
,vr,.v,'rv  lakr-  |.la.'.'  i-  vaviaM.'.  M.M  lV.'.,iU'ntl>  il  ai^.a.-  ...  !..■  l.-ni 
.„„.  „,',u„  w.'C'k-.  1  liax.',  li..u.'V.r.  al-..  ..l-.i'V.'.l  ,.n.li-a.-I.'.l  .'ii-.'- 
tliat  la-t,.l  a-  l..n^  a-  nil..'  w,.'k-.  Iii.'..m|,l..n'  .-..•..x  .vv  xMlli  lian-t...- 
,,,^,,i„„  „,'  „,,„,  ,,,.,,1,,-ili-  in...  til.'  .'linmi.'  vari.'.v  a,.|M'a.-  ...  1..'  a  .-a.v 
ox..,.,,.i..n,  in  .'..n.ra-  wi.l.  h.iii.' ...lu'--  ini;'.'.i..iw  -li-a-.-  in  uln.'li  .Ins 
i.  w,H  kn..wn  ...  1..'  11...  nn.M,ni.n..n.  In  a  lar-.'  ,'Ni..'n.'ii.'.'  I  liav.'  l.-'i-- 
.„nallv„l.-.'rv,'.l  l.n.  1  .'a-  tl'a.  r..ul.l  !..■  in.'ln.l.'-l  in  .lii-  .-a.-'-.n.  N.. 
su,.h  .'a-.,  lia.  ...■.Minv.l  a.  ili.'  .I..ln.~    IL.i.kin-    Il.-i.i.al,  an.l  (  M.  r  '  lias 

iirvi  T  -.'til  -iii'li  a  «a-.'.  ,     •  1    ,■ 

Of  otlwr   .li-.'a-.-    ..f  til.'    l<i.ln.'v    in    .ii.' .•-.■    .'t    >.vi.ii..Hl    l.'VtT, 

vinnallv  n.,.liin^  i^  a^  v,'.  kn„wn  ..lini.'allv.  Tli-  ninl.i,.!.'  a...l  .ho 
,lim,.,.  hn>,.li..M.a.a  ..f  WauiU',','  ,li.'  .x.-.'.lindy  -'a-v  i"t;"v,.  an.l  nu.lt- 
,,U.  .,1,-;.,.-..-  ■  aiv  at..'n.l.'.l  in  -...i.Tal  wi.l.  .l-  >vmp...m-,  ..r  a.  ni.xt 
'vi.l.  ,1...  a,.i.ra.~a.M'.'  .'f  all.nmi.inna.  Kv,.,i  ....t..w...'.liy  h.ma.nna,  .n 
,..,„s..,,n.n.v  ,.r  iiitim'ti....,   may   !..■  n.nsi.lcv.l   as  rx.'.r.lin-ly   .-aiv. 

GENERATIVE    ORGANS. 

Male  Gemtalia.-l>i-.a>.s  ..f  .h.'  -nal,.  ^■.■..italia  in  tl...  .•.M.r>o  ..f 

tv,,l.„i.l   f.-v,r  a.-.'  .....   -   tV.'.,n.M.t   an.l   i...i....-ta..t   a>  ar..  tli..~..  .,1   tl.c 

i;,;,,,!,,.      As    i„    ...il.'.-    i..t;'.'ti..ns    .liMas...,    .'^iM'.ially    va.-i..la,    ..;tla...- 

,,f    .11.'    t.-ti.'l.'    ...-.'ni-     in    tlic     .'.... i-s.'    .'1     tyi.l...ul 


nat.irv    atV.'<'ti..n- 


.  Il,«,.i-..i,.  ./.7,,..  ll.i.i..,..  II'.-','    /.'•/'■  '"I   " 

..,,./,.   ,/.    //.,/..    l!.l.   ii..   n,.!    ■■Ni.r.M>kru..kl..i...T,.--   r<.n  A.n„..sn,  .   Il.„„ln„./.. 

'■    ^:t.  ,1,.'   .'h.-i"  .—  ..f  -n    l!.'.'Ui...l.au-.n.   V,  rl. IL.I.ph^.- '■  '^-"-''- 

c.    IIV/-.:'""'./.  1S71. 


syyi'ln.us     |\7)   iiiMl-l  KAIIOXK 


195 


fiNcf.      Xiit    iiiiicli    i;iii    lir    siiil    ill    l:i  iicial    willi    I'ciriiril   tn    tlnir   Cn 


I-    tlli'V      ll: 


it    ;i-    \rl    liciii    ~c.    lli..r  .Mi;lil\     :iiii|    :i"lliiil"ilil  V 


ilii'il  ;i-  li:i«  llir  mrliili-  ot'   \  ari"!:!  I<  'lii:i''i ).    'Is  |pIiim(I  nr 'liiii-   aji 


■III-  ranh   at  tlic  Im-i 


i^iiiiiiiii:  lit'  tlir  ili-ra-i',  wliili-  it  i'  alini 


a   iiiaiiili-laliiii'  nt'  llir  la^t    |iart  nt'  tlir  ti'iiil.-    -tai:''  nr   llir  ti|--t    |ial'l  hI' 


<''ai\ali--iTiiri 


It 


;in-  u  itli   rhilrni 


ir   rvi'ii.  a 


-    I    ll. 


lii-iivnl 


•a-r,  w  itli  a  1 


'liill.       I 


II  aii\  r\  rill,   ll   i-  aliiin-l  alua\  -  al 


ll'lnll 


iiaikc.l  rlr\  almii  nt    lciii|ii  ral  lire, 


T 


ir   ti-ll 


■Ir  ami 


iiiil    llir  ciniliilv  iiii^  arc, 


iimlrr   -Hell   liriMiiii-taiiri-,   ul'iin    imliiratril   ami    -unllcii,   ami    llic   -kin 


it'  1 1 


-criiliiin    i-    nililrmd    am 


ll 


■i'a-iii|ial!\'  I'llriiiatiiii 


"111'  ti-lirli 


illv  allri-tn!   lir-1,  aiiJ  nt'tfii    ah 


Ir —  riiliillinnlv    llir  rlilillilv  nil 


i-   alVivtnl    llr-t    nr 
.1'   tl 


almir    I  I'.-liiirl'l 


ill-,   w  liii'li    raili; 


Itr     III     till' 


iiiiir-i'   lit    tlir    -|i('riiialir    runt    in    llic    aliilniMiiial    i'a\it\,  aiT  i^riir 


that    Ilii'V 


IrlillM'    IITI 


talil 


I'    iiiiliv  iiliiai- 


>l 


rr|i    ai|i|     ri'-t. 


I  rrilllllalinn     in     ITrii\rr\'    l-    tllr    rillr. 


III-  \\a-  rninidi 


tnl 


III    irnlll    till 


In     rniirlci'ii     i|:l 
llitllrrin   nc\rr    . 


'I     all      tllr 


•a-i-    iinilrr    iii\' 


ll,-' 


rr\aliiiii. 


1 


i-c'i'\iil    tl  riiiiiialinii    III    -ii|i|iiiratiiiii,  u  Im-li  a|i|M'ai-,  nii 


ill'.      In       ll' 


11'    cM'i'i'iliiiLily    rai'i'.      <^iiiir  i'\ri'|itinnallv   atrn|ili\ 


till'    ti-tlr 


I'   lIl'M'lnll-. 


II  a  I'a-r  II 


mlir    ni\   nli-i'i-vatimi    -tci'ilitv  in    tli< 


iiiali,  ili'iH'iiili'iit    ii|piiii   a/iii"i-|i('riiii.i,  \va-   with    in-nlialiililx   attriliiitcd    Ik 
a  |iii'\  inii-  biiali'i-al  ty|)liiiii|  nrdiiti^  fmiii  w  liirli  ni'nvirv  liail  t.ikcii  |ilai-r. 

I  liavr  |>('r-uiially  nhscrvcil  tv|iliiiiil  iiri'liili-  in  (1  i'a>r>,  ami  in  all  it 
v\a,^  iinilati'ral.  In  i  iii^laiirrs  ilic  tc-tii-lc  alniii'  was  iiillaiin-  I,  ami  in  2 
IiiL^rlliiT  uilli  till'  ('iiiiliilyiiiis.  'riif  atrci'tioii  aiiiM'ar.-;  mil  In  (ici-iir  in  clulilrcn. 
It  ili'Vc|ii|i-  i-liii'lly  ill  yiiuiiL'  nicii.  Five  of  my  patients  were  iiinler  tliirtv, 
ami  hut  one  forty-live  years  nhl.  .\n  interestiiiL'  stmiy  ii|miii  this  siilijeet  has 
Ueeii  iiiaile  hy  Ollivier,'  who  analy/dl  •'!  eases  of  his  own  ami  a  eoiisi.l- 
(  ri.hle  iiiiinher  from  other  .sown fs.  'flieri'  inav  lie  iafi:tioiieil,  hesiiles,  ainoiii,' 
Kreiich  ohservers,  Cervelle'  ami  Sorel,'  ami  anions.'  (ierinaii  ojiscrvers  es|n'- 
eially  Liehernieister,'  w  ho  ohserveil  orchitis  in  :!  cases  ainoiii;  L'dd  of  tV|ihoiil 
t'ever. 

A  late  review  of  the  cases  of  tviihniil  orchitis  has  lieeii  made  hv  Ushiier,'' 
ulio  collectcil  4:!  cases  from  the  iiteratiir<',  hesiiles  reixirtinj:  1  of  his  own. 
1  en  of  these  are  iiiciitioiied  as  liaviiij^  jrone  on  to  sii|i|)iiratioii,  ami  from  the 
|ius  of  .')  of  the.se  ca.ses  tile  typliniil-hacilliis  was  ciiitivateil.  Vnnn  a  stmiy 
ot  these  cases  lie  conclinles  that  in  most  iiif'aiices  the  comlition  is  iie|M'n(ieiit 
upon  infection  liiroiiirh  tlic  iilooil  with  lyphoiil-hacilii,  altlioinrh  the  |)os- 
sihility  of  infection  hy  coiitiiuiity  thriui!:li  the  urethra  with  tvplioiii-haciili 
or  other  Tnicro-orL''aiiisiiis  cannot  he  exclmieil. 

The  nccurreiicc  nf  eniis-intis  with  alitinrmal  f'fci|iieiicy  in  cmivalcs- 
<'ciit-    triiin  typlioid    fever    is   wnftliy  of  iiieiitinii,    liccaiise  at    times   ot" 


'  A'.r.  ./,  M/./.,  lK,H:i. 

'  (inz.   III,',/.   ,/(•>!  /l,'ij>..    I,«SO. 


'  Tf„';~.  ruri-.  1S74. 

«  L„r.  rif..  I'll  oil.,   p.    IPl. 


'  I'hihi.  M,,/.  J,.,ir..  vi.l.  i. 


196 


'lYrilnlli    I  I  VI  II 


pivat  |.ra.ti.al  im|M.iIanrr,  lln-  «a-  .  iii|.iia-i/.  .i  i,y  ( iii.  — iiiircr,  aii.i 
1  have  lV(i|ii(iillv  ..l,-.|-\(il  it  a-  a  cli-liirl.iii'.'  Ia.l.>r  (luriiit;  r.Hivalc- 
.■iiicr.  (  haiiL''-  ill  ill''  |"i>i-  :il'l":ii'  'Miviiiilv  raiv.  (  ..mplilc  ..r 
pai'lial  iraii-niir  '.!'  llic  "lyaii,  a-  lia-  Imvii  iii(iiliuiii<l  \<\  Ainlral,  I'ill- 
liiaiiii,'  ami  ..iIk  a-,  I   liavc  ikm  i'  ol.x  i\  id. 

Female  Genitalia.  —  A-  i-  inn  of  maiiy  dlliii'  intKiicn-  di-ta-i-., 
so  llic  l..i.'iniiiii-    and    ci.iirv  ..t'  l\  |.lioi(l    H'Vir    lia\  r  a  iltfmitc    iiitlu.ii.'c 

„| til,,    luni-tnial    llou.       It    ocair-   ciiiif   I'n.iiii  nils   .liiiin-    llir   tlr-t 

.lav-  .il'  till,  ili-ra-c.  ami  caiTa  r  tliaii  u.>iil,i  lia\r  Ihcii  i\|i.cl.-,i  diiriii^r 
lirallli.  At  tiini-  il  i-  likiiy  to  1..-  a-  livr  a-  ii-iial.  aii>l  at  utlicr  tiiiirs 
iMiuMially  ai.imilaiit  aii.l  im.tfactf.l.  In  llir  laltir  cx.nl.  .anfiil  cxain- 
iiiatinii  n\'  \\\r  uinitaiia  -liuiiM  aluav-  \»-  wm\v,  a-  aliMi-lioii  at  liir 
IxMrinnintr  "f  t\  |)ii(>iil  fcvir  may  ii.'  ivadily  r(.mial(il  iMJiind  tlic  iiia>l< 
dt'  alumrmal  nu'ii-lrualinii. 

It'  till'   normal    time  ot'  mm-tiMiatioii    i-   not    diir   until    two  to  tiiivc 

Wick-  alter  tl ii-t  of  the  tlvcr,  tlic   flow  iwiially  doc-  not  take  place. 

In   tr<iii'i~il,  ;ili-(ii« t'  in<n-triiatioii    i-   tlic   nil.'   tliroiiuli'iiil    lli<'  <'ntirf 

f.l.riic  period  and  diiriiiL'  the  tir>t  part  of  eon\  aie-.^eiice  ;  at  lea-t,  tins  i-* 
true  of  protnieted  ea-e-  and  tiio-e  piir-iiinL--  a  -(  \  tiv  cour-e.  I  lielicve 
tliat  diirinu''  tlie-e  period-  eoiniilete  al)-eiMc  of  ineiiMrnatioii  may  he 
e\l)eete<l  in  alioiit  tin  per  cent,  ot'  tlie  ea-e-.  In  tiie  remainder,  traiiM- 
torv,  -li;:lit.  rarelv  profii.-e  lieiiiorriiaoe  from  tlie  pnitalia  oeeiir>  in 
r;ltlier  an    irre;riilar   manner,  even    during    tlie   felirile  stap'. 

After  -evere,  lonir-pf't farted  attacks  of  typiioid  fever,  menstniatiou 
is  likclv  to  I.e  ah-ent  .'Vcn  after  .{.■fcrve-ccnee,  often  not  apiM.ariii^r  for 
two  or  tiircc  period-.  .Vfter  l.s-  >evere  and  mild  attack-  it  oficii  recurs 
dnriiij:  convaie-eence.  I'rofn-c  nteiine  licinorrliafrc  at  tlie  licifrlit  ui' 
the  disease,  witiioiit  >pe<'iai  local  can-c,  is  rare  and  of  oiniiiotis  imixift. 
It  is  analojroiis  to  a  ^iinila''  o<'ciirrence  in  ca>e-  of  licinorrhajrie  small- 
pox, and  occnrs— rarely,  it  i-  true,  in  conii)arisoii  with  it-  frei|iiency  in 
tiie  former  disease — in  ca-cs  of  ty|>hoid  fever  i.resentintr  other  "  licniur- 
rhairi<'"  symptoms.  Toward  tlic  cnil  of  the  di>ca-i  or  dnriii'r  conva- 
lescence, peri-iiterine  hcinatocelc  may  occiir.  a-  Trousseau  lias  ix.inttil 
out.      Still  fir  li<-  common  than  this  is  iieiiiatoinetra  (Martin-). 

So-..alled  diphtheric  and  .■roiipoiis  atVc-tioiis  of  the  ntcriiie  nmcoiis 
memhrane,  whicii,  iiiidoul)te<l!y,  i'ave  iiothiiij:  to  do  ctioloj:ically  with 
true  dipiitheria,  are  of  anatomic  i-.itiicr  than  of  clinical  interest,  jiist  :is 
are  the  hemorrhap'.  tiie  suppuration,  and  the  necrosis  of  the  ovary,  all 

of  which  dnrin<r   lii'e  <.dve  ri-e   to  -ympt -  ditlicult   of  interpretation. 

Mure   impoiiaiit   are   certain    alteration-    in   the   external    ircnitalia   and 

,   ;_,„.    ,.,,  ■'  Crntra/M./.   <i;i,ink.,  IKHl,  No.  20. 


M   1//7'<l/v     |\7)    I  iiMfl  /I  A  I  l').\S. 


197 


tlir  \:i;:iiiii!  (ililicr.        Ivi.iiiM  iii'tiic   ]:\\>\.[  III  ill.  mi,  (Icclll.iliil   ii|c,i:iti f 

till'  ^'rc;il(  T  :iii(l  lr~-.r  |;il,i;i  and  at  the  v:i>:iiiiil  nfiliir,  |i:iiiit'iil  cr.i-ions 
at  the  iimiitli  ,,|'  \\,f  iir.ilini,  tlic  latt<r  Ixiii^  not  nuciv  ilic  (!iii>c  of 
i~<liiiri:i,  arc  .if  ii.it  niiv  .nciinviicc.      A  r.iriii  .if  iiiiii-j,'.iii.irrlical  Iciik.ir- 

rlicii  iici'iirriiijr   "illi   < -i.l.nililr    tn.jiicn.'y    in    ihc  .•.,iiivv  ,,|'    iv|.lhii(l 

fever,  anil  whicli  -lill  iict.ls  a  tli'ir.ui^di  lia.'iiriiili.^ic  ii.\  .-lijiatinii 
sll.illl.l    lie    liii'iiti.ilie<l    llelc. 

Ill  a  iiiiiiil).r  .)f  iii^laiKo  I  lia\c  .ili-i  i\  .d  aiiile  iiillaiiiMiati.ni  ami 
sii|i|.iiiati.iii  .if  the  i^ltuiU  .il'  IJartli.iliii.  'I'akaki  and  Werii.r '  liavi- 
re|«iit.'.|  -iieli  a  ea-e,  frmii  the  Mi|i|)iiiatiiij;  tjlainl  .if  whieh  thev  iilitaliied 
the  typli.ii.l-lia.ilhi-  in  |iiirc  eiiltiire.  ( '.ini|ili|c  .,r  |.artial  ^.iiifjrene  nf 
the  \iilva  has  fre(|iienily  l)..n  r.|«irted  at  ilitfireiit  times  and  in  .lillir- 
eiit  e|)i.leiiii<s  (Il.itl'niaiin,  Lieliermeister,  S|.illniann  =).  I  have  oliserved 
tliis  cin.hti.iii  ill  1  eases,  twice  iii  ehihlreii  and  twice  in  adults. 
Ill  .iiie  iif  th.'  latter  lases  the  traii^reiic  was  a  se(|iii'l  ..f  hartli.ilinitis. 
All  cliiiieiaiis  ajriee  that  (.Miii^nne  <if  the  vulva  is  t.>  he  cniisideriKl  as  a 
fxra\('  syin|)t.iiii,  .leciiriiiij;  aliu.ist  mily  in  excccdinjrlv  severe  cases.  In 
tiie   rare  cases   in  whi.li    it    is   jMi-^sihle  t.i  dcni.instrate  a  l.i.al   cause,  as 

in    the  case  just    referred   to,    n very    soinctiincs  ciisiics,  then    ^reiicr- 

aily  with  extensive  cicatricial  ilefects  extcndinir  int..  the  vulva,  .ir  even 
with  vesical  iir  rectal  tistiihe. 

Inflammation  of  the  breasts  in  tiu •>.■  ..f  ty|)h.ii.l  fever,  as 

has  been  ilescrihcl  hy  liciidct,'  ajipcars  In  he  .|uitc  rare.  Slight  traiisi- 
t.iry  tuinelaeti.iii,  li.iw.'ver,  is  in  my  <'X|)ericiice  s.nnewhat  more  e«iiim.)ii. 
'I  iiis  may  rca.lily  he  .iverl.i.ikeil,  as  it  iisnallv  ncciirs  in  severe  rases  at 
the  licif,dit  iif  the  fclirile  stajre,  with  the  terminati.in  .if  which  it  silhsidcs, 
s.)  that  the  patient  is  ii.it  really  c.insei.ius  nf  its  |)rcscnce,  and  it  is  nirelv 
a  s.iiirce  nf  c.im|)laint.  'Perminati.m  in  su|)piirati.iii  appears,  as  in  the 
.ase  .if  the  testicle,  the  thyr.iid  jrland,  and  the  ))ar.itid  jrlaiid,  bv  no 
means  t.i  be  the  rule.  I'mbably  the  ba.'illils  of  Kbertli  is  the  excitinj^ 
aireiit  of  the  iiiHammati.iii  in  the  majority  .if  cases.  It  mav  be  iiien- 
lioiied  tiiat  I  have  olwerved  sli;rlit  mastiiis  in  2  eases  of  tvphoid 
fever  in  yoniif^  men. 

The  relation  between  pregnancy  and  typli.iid  f.vcr  is  deservin<rof 
lull  c.insiderati.iii  from  both  a  clinical  and  a  pr.i},mostie  standpoint. 
Reference  has  already  been  made  (undiT  the  subject- of  Ktiolojrv)  to 
predispisition  diirinj:  jrnividity.  '  .V  study  of  the  litcr;itiire  of  this  sub- 
ject disci. ises  ditVcr.'iices,  often  actual  contnidicti.ins,  which  are  not, 
li'iwever.  due  in   the  least   t.»  the  .-mallnos    if  the  statistics  consl.lered. 


# 


X'if.  /.    //,;,.,     lid.    ix\ 


.1 /■<•/,.  -/.   M,-,/..   IHSI. 


Clin.  Dial. 


I 


1!)K 


/ 1  rii"'i'  n  \  I  n. 


Tlic-  m;ii..ril\   ..r  \m1|(  r-    -i^''    iinl'.i\  "ImI'I''    n  |H.rl-.  -laliiiL'    lli.it    .liim.-t 

;,lu:i\-    ;ili..i-li r    |>n  riiiilmv    I.iIk.i-  (Mriir-,  niili    i;iv:il    iLiii-i  r   I"    llif 

liH-    nf  ill.     iiiolliir.       Ill    ins   .  \|Mri.  ii.r    llir    pinl    !•■    |.r. -naiil     w 'il 

MitllriliL'  tiMin  l\|,li..i,l  r.\r|-  i-  11. .1  -.  Mival,  .■.ilainlv  ii.'l  .■..iii|iaralil.' 
t..  ill.,  .laiii:.!-  all.  ii.liiii;  llii-  .■..iiiliti..ii  in  .a-.  -  ..!' -mall  |...\.  \.  a.  l•lll.- 
l.•— ,    .^i-asi.iilv     i-    I"    I"-    I'.n-iil' ivil    a    -.ii..ii-    .■  .in|.li.ali..n    ..I'    l\pl I 

A     iMiiiil..r    i.r    |iali.iil-    pa-    -al.  Iv  llin.ii-li    lli.'    alla.k    ..I'  t\  |.li..i.l 

iVvcr  uilli..iil    iiil.ll-ii|ili"ii    ..r  |iiv^iiaiic\,  uliil In  r-    n  ."S  rr,  in    -|iili' 

dt'  al...ili..n  ..r  |.r.MialiMv  lali.ir,  in  tlir  latli  r  .miU  il  liiiM-  I'V'H  "ill" 
il  lisiiiu'  iliilil.       Ill  'illiii'  I'^i-'-^  'Icatli  ...-.■iir-  iiiiiiii-.lial.l\   at'l.r  iiil.Tni|i- 

ti t"  ill.'    pivLrnaiiiy    ..r   ..ciiir-   a-   a    iv-ull    ..I'  -.a.iv    .•..iii|ilii'ati.iii-.' 

'I'll.,  .an-.'  ..r  ^inl.iiii  ilcalli,  .ill<i nilTiiiu'  williiii  In.iii    I  u.iilv -l'..iir   t<> 

thiris-ix  li..iir-,  i-  u'l'inniHy  tlif  Taiv.'  aiiiniiiii  ..f  l>l.".'l  l"-t.  AiiLiiiii- 
til.,  .■.iiiipli.ali'.ii-,  -ijilii-  .■.iiiiiili..ii-  with  |i-.uii.iili|>iilli.  rii-  ami  '/an- 
.riTii.iii-  iliaiiL^i-  ill  llif  III.  riiir  tiiii....n~  iii.iiiKraiic  -li.nh  I  l.c  in.iili'Hiiil. 
Miill.r  -tall-,  li"u.  \.T.  tlial  l\|ili.iiil  |iali'iil-  aiv  ii.'t  iii..rr  lial.ic 
ihaii  ..ill.  r-  t"  .■..iii|ili.ali..li-  "I'   laln'i-,  -ii.li  a-  li.iii..rrlia<;i'. 

In  niv  .AiMTJ.n.-.'  lli.'  a^:.'  ..I'  lli.    piv-nanl   u.^nian  aii.l    lli.'  ]><v\n,\   in 

])f(j:iiaiwv  liav..    1 ,,ii-i.l.ral.li'    intln.n.v   ii| tin-  int.  i  rii|ili"ii  "f  tin' 

latter,  a>  iniiilil  !'<■  tli.'ii^lit  in  a.ivaii.-.'.       I  I..u.\ii'.  it    may  !..■  -ai.l    tliat 

if  ill..    inl.rni|,ti ...iir-  in    tlie    lal.r   iii..nlli- ..f  i.TVMnaii.A  ,  tlii^  pn.-- 

11. .-i^  i-  .ii-liii.tlv  111. .IV  iiiifav..iaM.'  than  if  it  tak.-  |ila<v  .liiriiiH;  llic 
tir-t  fiirlit  ..r  t..n\v.-.k-.  N\itli  n;iar.l  L'tl ...iinviK...  ..f  tlii-  .•..|||- 
|.li.ati..ll  in  ivlali.iii  t..  tlir  -tatre  I'f  lln'  'li-' .im  ,  it  may  !«■  -ai.l  that  the 
.laiiL';!'!-  i-  LTrat.-t  .iiirin...-  tli..  f.l.rilc  prri."!,  ami  that  in  lli..  tir-t  wr.k 
(if  tlii<  ixri.Hl  alM.rii.iii  ...■.iir-  far  !<■>-  .■..miii..niy  ili.iii  in  th..  H.c.inil  ..r 
third  \V(...k.  In  pr..tract...l  ca-cs  ..f  typlmi.!  ti^v.-ruith  a  iiiark...lly 
r.initt.nl  ..r  int.  rmitt.nt  t<.mi>.'ratiirt-i'iir\  •■,  I  li:ivi'  ..l.-.rs  i-.l  tin-  .■..lll- 
l^li..ati..ll   n....|ir  a-  lat..  a-  th.'    fmrlli  week  ..f  tiie    frv.r,  aii<l    .'V.-ll  lal.f. 

If  th.'  f.l.ril.'   -ta-i'    ha-    l.r<ii    -nccfs-fiilly    i>a>s<..l,  tin tJ.H.k    In nic> 

m.iiv  fa\..ral.l...  On.'  -h.ml.l  av.ii.l,  li..\M'V.r.  makinir  .l.tinit.-  |.n.iiii-.s 
f.r  th.'  |..ri...l  ..f  .M.iivah-<vii..|..      Kv.n   at   tin-  .-tai;<' al...rti..ii  mikI   pn- 

matiir..   lal...! .iir -.imitimr-,  i-pc<-ialiy  in  -n.atly  nKlin-.-.l    patient- or 

with    til ->t    .if  ...implieati.iii-. 

A-  an  ..vi.l.-n.'i-.>f  ill.'  r..|iiarkahlc  variahility  in  tli..  -laleiiieiil,-  .if  writers 

with  re<:ar.|  tn  tlu urse  an. I   pr.iL'ii.i>i>  nf  typliei'l  fever  in   -r:i\  i.l  wnnieii, 

it  iiiav~l.e  iiieiiti.iiie.l  that  Mun'liis.ni  >tMt..>  that  the  preiliinsis  is  alwiiyH 
i_'rnv..'in  th.'  p,..seiii'e  ..f  a.lvaiiee.l  ltmx  i.jilv.  lM.|i..viiiL'  llmt  ii  fatiil  tenniiiii- 
ti.in  t.i  preiiiatiire  lilh.ir  iiiviiriahlv  .le.iirs.  Lielieriiieisler  ills.,  e.insi.lers 
crrnvi.lilv  iis  ..x.'e.'.liiiLrly  .hinL'ereus.  Of  1.^  pn'L'iiiiiit  w..iiieii.  he  .ihserve.l 
I  S...  ill  tlir  -.•.•ti..ii  i.ii  Kii.l.i-x.  th.-  f..iidili..n-  for  Ty|ili..iil  K.'V.T  in  the  Ki'tii-. 


vvi//'/'M/v   i\/)  ( '>\iii  I'  \  ri'i\s. 


!ti» 


nlmrliiiii  ill  1.")  anil  Ar-.xlU  in  li.  liiiim:!;. ,  in  >:iv  lli;:!  ''t'  all.  Of  .">  |)rfirii:ii:t 
Will  I II  11  iiiiiiiT  llic  iili.ii'rviitinii  i>t'(iricnitiiipT.  :i  iliuil.  jn^  unit  lire  lalwr  li:i\  in;; 

I.,  nil  ri'.l  ill  nil.       I'r v   Liiiwir   fliili^lii-n.  wliii-li,  it    i>   Irilc.  iii<  liiilr  "iily 

till-  -iiiiill  iiuiiiIh  r  uf  I  I  rM-r".  it  iipiK'unt  lliMl  llir  _'iii\  iilily  «ii.«  iiilii  iii|ilcii 
111  mII  lull  I.  ami  cliiilh  oiriiiTfil  ill  .') — :S."».ti  jht  rini.  M\  I  hiiiiliiirL'  cxi'iri- 
I'liri'.  nil  llii'  ollnr  liainl.  I-  i|iiii<  I'l  <  nnililt'.  timl  I  \m>iiIi|  uIImiIi  -niiif  iiii|Rir- 
I  a  lice  III  ii.  a>  II  1-  iimri'  rMiii.--i\i-  mill  wii.-  iilii,iiiir<l  ill  I  111'  ciiiii-r  'it"  «  m'Vcre 
i'|iii|i'iiiii'.  (  )t'  all  till-  uiiiiii'ii  niiiiiii;.'  iiiiijcr  oI>mt\  alimi  in  !'*•'<(>  ["^xT,  .'!■•< 
:i.  1  |ii-|-  ii'iil.  VMTi-  :'ra\ii|.  '  M'  iIiim-.  l  \Miil  Id  Iriiii  ii  I  VNcrc  ilcliMrcil 
illiniiL'  riiiivali-iciirc  nt'  liviliLT  cliililrcii,  wliilt-  l(  I'J.  1  jht  rent.  wire 
ilisi'liar^'i'l  at'liT  iiriivirv  I'luiii  llir  iillaik  of  ly|ilii)iil  liver  «illioiit  i'ilirrii|i- 
liiH'  lit'  till'  pri'iriiaiirv.  I'i-c;.'iiaiii-v  «a-.  lliii.«.  iml  lliriali'iii'ii  liv  llii'  atlark 
(if  lv|iliiilil  liver  ill  cxailly  liall  nt  iii\  |ialiiiil.-.  (  »f  tin-  niluT  |iiili(iil.-.  in 
wliniii  aliiirlinii  nr  iirfiiiiitiiri'  liilmr  Innk  |ilai-c.  :!  ilicil.  'I'lu-  iimrlalily  iliirinj,' 
|ircL'iiaiiiv  wa*  llun  liire  7.^  |Hr  iiiil  I  liail,  lui-iilcs,  a  similarly  I'avnr- 
alile  i'X|HTiriiri'  at  llrrllii  lufori'  llir  llainluir;;  i'|iiilrliiic.  It  -linlllil  lie  IiiiMI- 
liniit'il,  t'lirtlii-r.  lliat  reMilt.-  >iiiiiliir  In  my  nun  liave  lnfii  rcimrtfil  fmiii 
Kill  liv  (iiilli,'  «liii  aiiinii.'  '.'  |ialii'iil.'*  hIimtvciI  iilMirrmii  in  4  ami  ili-atli  in 
Iml  I.  Al-i,  Itri/.  ■  rr|Mirl-  I'riiiii  /iriii-M'ii's  ilinie  al  Muni' li  llial,  of  !'  pri  l;- 
iiaiil  uniiicn.  alinrlinii  t'aili-il  In  ni'Mir  in    >. 

Saii|iiiii  '  riillri'tnii  t'l'iiiii  \ariiiii«  -mircr-  tlir  -lati-tir-  nt'  -'■'}'■'•  ca-cs 
lit'  |>rc;:iiaiiry  liiiriiii:  tv|ih'ii'l.  AlMiriinii,  iiii-rarri.ine.  nr  |iniiiatiiri' 
laiiiir  iiniiirnl  ill  lot)  ut'  tlii-c  i'a-('~.  I'ratli  o<riirrc<l  in  ."{7 — lii 
|ii  r   I'ciit. 

DIGESTIVE  ORGANS. 

I,ips,  Mouth,  Tongue,  Pharynx,  Parotid  Glands. — Wliil<> 

ijiiiiiiir  iiiiM  attack-  tlii-r  |iai;-  ixliiliil  -linjit  cliaiitr''-  "''  allrialiniis 
that  arc  nut  cliaractcri-tic.  in  llic  -c\crc  ami  unr-t  ca-cs  tlicv  arc  likdv 
111  aci|iiirc  -I)  |iiciiiiar  a  diaractcr  a-  In  ciin-tllntc  an  ini|Mirtaiit  ii.'iri  of 
tlic  general   clinical    |iiciiirc.      Kvcii  carK  llic  niiicniis  nicnilirnnc  uf  the 

11 t!i.  lip-,  aini  tiiiiLriic  cxliiliit-  a  tcmlcnc\-  to  drync-s.      At    iIk-  -amc 

time    the    latter   i-   i -c  nr   Ic--   cnatcil   ami    -vMilleii,  vvitli   «li-liiiet  ami 

iil'tcll  ilci  |i    ilil|ire— iiilis  i>t'   tile   tectll.        At     llic    liciirllt    III'  tlic    (li-casc  till! 

ii|i|icr  li|i  i-  likely   in  lie   rctiiietcd   ami   llic   ii|i|Mr  lutli   (x|(n-c<l.      The 

tiiii'j-iic   ami   llie    li|i-   tlieii    li inic   cnxcnil   wiili   a  ilirtv-hruwn,   vi-eiil 

ile|Hi-it,  rapiilly  iimlcri.'niiin'  ile-ieeatinii.  'I'lie  drv  iniiciiii-  inciiilirane  nt' 
the  li|i-  hcciiiiics  fissured,  tile  iriiins  are  siMiiiirv  Mild  lilciilin^r,  and,  in 
cliildrcn  wliii  cniisinntly  pick  at  tlic  sure  lips,  cxtcii-iNc  ce/cinat"iis  and 
nleeiati\c  prn(e--e-  readily  di  \clnp,  with  niarki-d  -uellinir  "'  thi'  lips 
and  the  lis-iies  almiil  the  iiiniitli.  In  rare  ea-es  eiim|ilete  si-nrliiitiit 
detaehiiicnt  and  iiiccnilinn  nf  the  irnnis  take  phu'c,  with  at  times  pretty 
tree  heninrrlian'c. 

The   tniin-iin  at  fiivt  is  fre(|iientlv  cnvcrcd   nnlv  in   the   tiiiddle  with  .1 

'  /„„•„,.  /),,»,.  Ki.'l.  issr, :   iiii'l  /),,/^,■/,,  . I, ■./.(■.  /,/;„.  Mr,/..  H'i.  x\xix..  S.  140. 
'  Dr„t.-<.-/,.  Afr/i.   t.  kli,,.  Mai..  IJU.  xvi.,  xvii.,  .vviii.  '  r/-.'.«f,  Nancv,  18K5. 


rvrji'iiii  I  i:\i:i: 


If 


m 


iimri' iir  Ic^~  liiavy  wlilti-li  it  w  liiii-li-\rllo\\  il(|iii-.it,  while  il-  -wnllcn 
iliai'Llill-,  marked  willl  llir  ilii|)l'i--~i(i|l- nt' the  leilh,  ai'e  i:r'';iil\'  feildeiled. 
In  Millie  ill~lailee-  it  liiav  he  e(iiii|ilete|\  eii\er<'d  a-  earl\'  a-  thi'  lilvt 
\\vv\s    Ivy  a    tiiiek  coatiiiL:,  which    al    lime-    i-   (M-i'(ih>red   diit\    hrowti  (ir 

(•Veil  liiaek  hy  t I    I'ld  meiheiiie.       |)iii'iiiL;    iheearlv  iieriiid  nf  the  di  — 

ca^e,  at  tlie  ht'i^iiinillL;-  and  the  liiid<Me  lit'  liie  tii-t  Week,  the  tiiMJ^nie  i~ 
likely  ti>  he  >till  iiiiii>t  hy  day,  exhiliiliii^-  a  liideiiex  to  dr\ii(>.-  diih 
toward  e\ciiiiiu;  ami  lii;^lil.  In  the  >eeond  week  ot'  -evtle  ea-e-  it  can 
he  ke|it  inoi>t  only  with  ureal  care;  it  i>  tllel-  e\tell<led  w  itli  dit1ielilt\- 
and  is  Ireiiiiiloii- ;  it  ajipears  le>-,  ii'  at  all,  .-Wdllen,  and  in  le->\>ell- 
eared-tiir  ]iatieiit>  is  hi-own,  dry,  eiierii>ted  and  lis-iired,  and  hieed- 
readily  t'ni'ii  the  ti— lire-.  Tlu'  eoatiiii;-  of  the  toiii^ne  di,-a|i| tears  at  a 
time  de|)«'lidini.'  ii|iiiii  the  eharaeter  of  the  indisidiial  ea-e,  liiit  ilsiiallv 
at  the  e;,d  (if  the  second  or  in  the  liceiiiniuu-  ,,t'  the  third  week,  iisiiallv 
di>a|i|H:iriiiji:  first  at  the  tip  in  the  form  of  a  t.ia' ^le  and  at  the  mar- 
j;iii-,  then  <ncr  the  entire  tongue,  so  tl-t  the  oi^aii  then  a|i|)ears 
smooth,    red,   dry,    and    thin,   and    more    jiointed    than    ir-iial. 

S'Veral  tiictors  are  res|)on-ihJe  fir  the  ominous  dr\  iiess  of'  the  tonjriic, 
namely,  the  fehrile  teliiperatiire,  the  diminution  in  -alivai-v  -ecretioii, 
roiistiiiitly  kee|)ine'  the  month  o|)eii,  and  the  iliir 'li-lied  dc-iiv  of  the 
somnolent  patient  to  iiioi-ten  the  or^aii.  'J'yphoid  patients  with  a  drv 
toiiirnc  always  exhihit  more  or  le-s  marked  derani;-ement  of  coiiseion-- 
ness.  The  toiiniie  in  ca-es  ot'  typhoid  (('Xer  does  not  cxhiliit  anv  ('is- 
tinctivc  iiiorhid  manitestation-.  Its  altcratiotis  Iiccoiik'  ciiaractcristic 
oiilv  I'roni  the  |)eriod  of  oii-et,  the  inteiisitv,  and  the  arraiiiicnuiit.  An 
early  appearance  and  a  tiiideiiey  to  dryne—  ot'  the  toiiune  are  of  diaj;- 
nostie  ini])ortan  v.  'V\w\  n^pioeiit  a  ;'oii-piciioiis  asso<aated  iealiire  of 
llic  typhoid  -tafe. 

McCfae'  has  repoi'tcd  a  ease  ot'  i;lo--itis  comiiiL'  on  diiriiii;-  con- 
valescence from  ty|>lioid  fi'Ver.  The  on-et  wa-  on  the  tweiitv-tifth 
day  of  normal  temperature,  and  with  it  occurred  a  ty|)ical  rela])-e 
lastintr  two  weeks.  IJeeoverv  was  complete.  He  has  al.-o  collected 
several    other  ca-es    from    the   liter.itnre. 

Of  peculiar  eh.-inu'es  in  the  mucous  memlirane  <it'  tln'  nioiith  and  tlie 
])liarynx,  depo-ils  of  tlirii-h  especi.illv  are  to  lie  mentioned.  These 
occur  only  in  extreiiielv  -evere,  protracted  ca-es,  or  ill  patients  who  have 
heen  ]>re\ioii-ly  ill,  and  in  whom  the  care  of"  the  iiioiith  has  liceii 
ileLdectod.  Under  -iich  circiim-tances  J  have  seen  the  deposits  extend 
di  'vn  tlie  esojilia^fus  to  the  reLri"n  of  tlu'  cardia,  and  even  to  coiistitnfe 
a  serious  oh-truction  to  hreatli'iiLr.      'I'he  occurrence  of  a  sevi'iv  ca.-e  ot' 

'  ./-,/,,,..   Iln/J.n,s   /A, .7,.    liu/l..    v.il.    i\. 


syMI'TDMS   AM)   <  OMfl.liMIDSS. 


201 


llii-ii>li  ill   :i   liii--|iit:il   (liM-  not    ictlcct   cnditnMy  ii|Min   the   iiicilic-ii   care 
:iii(!   !!;!'   II  :^^illl.^ 

'I'lic  .-inictmc^  (pf  the  tiniccs  cxliihit  \iiriiMi->  cliaiijrcs  in  cases 
of  tyidiiiiil  t'evcr.  L\  iii|i|i(iiil  >\\clliiijr  df  tlic  ton-ils  and  tlie  |>alatine 
aniies — to  wliicli  reicicnce  lia  •  already  liecii  made  (in  tlie  cliapter 
<m  Anatomy) — a|i|)eai->  to  me  to  he  rarely  (lenioii-.trai)lc,  at  lea.-t  elin- 
ieally.  i)iit,r:ict  ai.  1  Cliaiitcmes.if  liavu  oliservetl  such  iiitiltrations 
imderijfo  disintefrration  witli  tlie  siii)se(|iieiit  f'ornuitioii  of  ulcers,  in  the 
floor  of  which  ty|ihoid-l)acilli  were  demonstrable — a  |>rucess,  therefiire 
that  is  prohahly  coiii|)aral)le  to  the  sjiccilic  le-ioil  in  the  intestines. 

In  the  larjre  majority  of  eases  tierc  is  but  slight  iuvolvemeut  of 
the  pharyngeal  structures,  namely,  ino<lerate  swelling,  aud  fre.|ueutly 
eloudincss  of  the  iniicoiis  membrane  of  the  soft  palate,  the  tonsils,  and 
the  ]iosterior  ]iharyngeal  wall.  In  the  second  and  third  weeks  the 
pharyngeal  structures  participate  in  the  dryness  of  the  reuiaiiider  of 
the  month.  They  are  then  ])rofiisely  covered  with  exceedingly  viscid 
mucus,  readily  d<siceating  into  crusts  and  filaments,  and  occasionally 
l)ocoining  a  serious  obstruction  to  swallowing  and  breathing. 

It  is  exceedingly  important  to  realize  that  syiuptoms  of  angina  may 
be  i)r<'seiit  as  early  as  the  beginning  of  the  tirst  week  of  tyj)hoid 
fever,  and  that,  together  with  chilliness  and  slight  elevation  of  tempera- 
ture, may  at  times  constitute  the  earliest  and  the  only  manifestation 
causing  the  patient  any  inconvenience.  Under  such  circumstances  the 
mucous  membrane  of  the  pharynx  and  the  tonsils  appears  more  or  less 
markeilly  reddened  and  spongy.  In  addition  there  are  not  nirelv 
|)resent  upon  the  soft  palate,  the  palatine  arches,  and  the  tonsils  isolated, 
rarely  mimeroiis,  whitish,  at  times  slinrhtly  elevated  sjw)t.s,  varving  in 
size  Irom  that  of  a  lentil  to  that  of  a  i)ea,  which  represent  areas  of 
circumscril>e<l  granular  <loiiding  and  tumefaction  of  the  up|)erinost 
layer  of  the  inucous  nieinbr-ane.  (Jenerally  in  the  course  of  a  few 
hours  siii)erfieial  exfoliation  takes  place,  leaving  quite  shallow  re<ldish 
erosions,  covered  with  a  thin  whitish  deposit  and  surrounded  bv  a  flat, 
irregular,  ofttui  vividly  reddened  margin,  wliicii  is  never  infiltrate<I.  If 
the  parts  are  kept  sufficiently  moist  and  clean,  the  lesions  do  not 
furtiier  increase  in  size  and  depth,  and  they  liave  almost  alwavs  dis- 
aiijieared   at    the   beginning  of  the   second   week. 

At  times  tills  MffeetiDn  of  tlie  tlirout  beeonies  so  iironiinent  a?  to  give  rise 
1"  error  in  diairiiosis.  I  have  in  2  instances  observed  such  palv'iits 
R'limlte.l  I,)  tlie  hospital  willi  a  diairnosis  of  diplitlieriii  and  croup,  res|H'C- 
tively.  la  one  instance  iiicipieiit  scarlet  fever  was  siisppeted  beeaiiso  of 
the  assoeiaIe<l   presence  of  a  sli^'ht   initial   rasli.     In   another  ca.se  in  which 


"m 


I 


^ntivt„m/s^x:r^_ 


M-^?- 


rmi 


•J(  >-J 


ryi'iKtifi  n.vi.ii. 


the  :iirfcli(m  of  the  lhn.;il  exi^l.■(l  lo-ilh.r  with  un  almiidaiil  |■o^e(lh.u^  eri]|)- 
timi  upon  the  trunk.  ;i  (li;iL'ii"-i>  of  syphilid  u;i.-  made. 

'I'vphoiil  an-ina  ^\a^  evi<hiilly  known  to  earlier  wrUers  ;  at  any  rale, 
certain  r-latenienl.-  made  l>y  Loui>.".lenner,  ami  Chonud  with  refrard  to  early 
iuvolvemeut  of  the  pharv  iiL'eal  Mructnre.-  in  ea^.e^  of  typhoid  fever  are  indi- 
cative of  thi.-.  Sulise.pienllv  it  di.<appeare.l  for  a  time  from  the  literature  and 
the  memorv  of  phv^ieian^.  iii  pari,  perliap.-.  ^eeau^e  it  varies  e.\tremely  in  fre- 
cpieiiey.  at"(lill'ereiit  times  and  in  dill'erent  places.  Thu.s  I  oliserved  it  ipiite 
rarely"  in  the  vears  in  which  typhoid  fever  prevailed  extensively  m  llam- 
hiir};!  while  it'  came  umler  my  uhservatioii  with  remarkahle  freipiency  and 
ill  marked  d.-ree  at  certain  limes  in  l.eipsic.  So  far  as  1  know.  thi>  varietv 
of  aiii;ina.  which  po>M's>e>  a  certain  ileirree  of  importance  a>  an  early  niaiii- 
festulion  of  tvphoid  fever,  has  not  yd  iieen  studied  bacteri(do,iricall.v.  '1  his 
niijrht  prove  an  intereMin-  undertaking  that  would  jKissihly  yield  iliagnostie 
results. 

Actual  (lii)litlieric  atVc  lioiis  ..f  the  ii!iafyii<;ea!  stnictiire>,  siicli  as  liavc 
lieen  descrihcd  l>y  ( iiic»iiij:cr,  Oiilnioiid,'  and  otlief,  at  tiic  iiei.L'lit  of 
the  disease,  towanl  the  close  of  the  sec. ml  or  in  the  thifd  week,  are  jiroha- 
bly  to  1)0  included  aiiKiii.i;-  the  true  conii.licatinii~.  In  any  cvciit,  they 
are  e.xtfemelv  rare  occurrence-,  that  yd  rc(piirc  exact  hacteriolooic  inves- 
ti'Mtion.  I  have  neix.nally  not  a-  yd  eiicountercil  a  <'a-c  of  this  kind. 
The  exteiisi<in  ol'  the  atrc<Mion-  of  the  throat  ahove  dc-crihcd  to  the  iia>o- 
pharyntreal  space,  the  Ku>tacl,ian  tiil>c<,  ami  the  middle  ear  will  he 
coiisidci-ed  at    another  place. 

Thcalterali.iiis  in  the  ].aroti(l  gland,  and  esiiecially  the  iiitlaiiiinatoiy 
Ic-ions  of  thi-  ofiran.  in  ca^s  of  typhoid  fever  arc  ipiite  iiniiortani, 
(>vcn  though  tliev  are  not  >o  coniiiioii  as  they  arc  jreiiefally  hclicvcd 
to  he.  .\-.  i-  >o  often  the  ca>e  with  specially  iiainl'iil  and  conspicuous 
disorder-,  the  frec|ii.'iicy  <.f  paroliti-  ha-  heeii  Lnvatly  overc-tiniate.l,  1 
have  pi'i'-onally  (Idennined  that  during  the  Ilanihurg  e|.ideiiii.'s  only 
0.;l  per  cent.,  aii.l  in  I.eip-i<'  O.o  per  cent.,  of  the  patients  exhihitcd 
inflaiiiniation  of  ihe  parotid  gland:-;  and  in  the  statistic  of  IIotTniaiiM 
relating  to    the    lia-l.^    cpi.leinic,    paroliti-    wa-    noted    in    Hi    of    ilidO 

(.;,>,.s 1    ]»  T  cent.       K.ceiitly  ]iafotiti^  apjuars  to  have  l.ecoiiie  even  less 

c,,ininon,  and  this  is  prohahly  due,  in  jmrt  at  least,  to  tiie  greater  care 
given    ixenerally  to  the   iiioulh  of  the   patients. 

Parotiti-  devcloi>s  generally  on  one  -idc  ;  rarely  liotli  glands  arc 
involved  -ynehroiiou-lv,  while  disea-e  ,d'  hoth  -llcee-ively  i-  more 
cmimoii.       I'an.iiti-     i-    u-iiallv    a    manife-tatioii    at     the    height    of    the 

.li-ea-e.  toward    the    end    of  the    -ecoml    or    the    third   ■,veek.  altl gh    it 

may  conic  under  ol.-ervation  al-o  later,  .and  even  diiriii-  coiiv  ale-cciK'c. 
It.- Clinic;  1  feature-  are  -candy  ditVe-ent  from  tlio-c  <if  intlaiiiiiiatioii  of 
the  glaie.U  under  wiher  (  on<!iiion>.      The  alVectioii  u-iially  o.eiirs  in  very 

1  llrr.  ,1,    ),.,'./.  ri  ,•/,//■.  ./.    /•.//'.■..  .luly,    IK.'i.j. 


?^V:.?%^^i.3m^^9?f^^' 


SYMl'TOMS   AM)   (OMrLIC.l'I'K/ys. 


203 


III    Mini     M 


lri:iilv  iniicli  riMliiicd    in(li\  i(lii:il>,  wliicli 


fact   1 


las  an  in)|>oit:iiii 


l>r:iriii;j:  nil  tlu' I'lunsc  and  ^vlll|)tl 


.1'  cax' 


ni>  lit'  till'  ruMijiliratioii.  In  tlic  niaj'Tity 
the  ntniiiiaiuliliiilar  |)iirtinii  tii-t  biruiiK-  >\viillrii,  at'tcr  wliidi, 
with  liu  ( \((|ili(iii-,  the  (iitirc  ipi'frjiii  i>  iii\iil\ril.  Tlif  aU'rctinii  i>  >i> 
painful  lliat  even  id'ofomidly  xipnrii-f  |)ali(nts  arc  n.iiM'idii-  of  its 
(■.\i~l<ii<'c.  lint  ranlv,  and  tlnii  in  (•a><>  of  incta.static  urijrin,  it  xt-  in 
with  a  chill,  while  a  ciirrc>|«iiiiliii;r  clcvatimi  of  tciii|Mratiii-c  withont  a 
chill  i-i  (liix  rvcd  aliiinst  iincxci  ptiuiiallv.      The  atfcctimi  niav,  as  1   have 


repeatedly 
alile  teml 


i-ved,  -lili-ide   withniit    siippiiratinn,  even   alter  enii^idci- 


eriie— ,  s\\( 


iliii'r,  and    icdiicss  ha 


\e    been  iire.-cii 


It.      Wh 


pil 


nitidii  iieciirs,  as  it  dues  in    must  case-,  it    iiivi 


lives  at   till 


ip- 


purtion  ef  the  intlained  trjaiid,  and  at  ipilur  time-  the 


ihe    latter  event     I 


uive   (leea-iiiliallv    lieeii    alilc    to   e 


les   l)iit  one 


I    tiic 


itiri 

iireaii. 

\tra 

•t    frnii 

isiiiii  Wdimd    lar;:e   purtioiis  ul    Ihi imeetive-tis-uc  structure  nt   tin 


f  th. 


and    in    the   ti'Vin   of  ncci'oli 


d-. 


With  rcirard  to  the  mode  of  origin  of  typhoid  paroiiti-,  the  view  of 


Vircl 


low,'  that    It    1-    due   to  e\ten-lon    ■ 


if  infection-   processes  from   the 


iiioiith  throiitiii  the  diiet  of  Steiioii  to  the  ulaiid.  is  certainly  correct  for 
Millie  cases.  Ill  several  case-  I  have  ol)-er\ed  parotitis  ncciir  ill  as-oeia- 
lion  with  ulcerative  slomatili-,  especially  in  the  vicinity  ot'  the  papilla 
of    Stciion.      .\l)ove    all,    it    should    lie   kept    in    mind   that    tlii'    ;^laiids 

ill    colisciiilelice  of  tiic   action  of 


ire  more   Ireiiiicnllv  direetlv  iiiv 


lived 


the  tvphoid  toxin-  than  are  other  oriraiis  {^I'f  -eclioii  on  Aiuitoiny). 
.VI  II,  the  tyjihoid-hacilli  theniselvcs  may  in  some  eases  be  t!  ■  direct 
excitants  of  the  inflammation.  .\t  hast  I  ca-e  has  heeii  rcporliKl 
(.laniiwski -')  in  wlii<-li  a  pure  eiiltiirc  of  the 
taiiicd    from  the  suppiinitiiit;  lilaiid.      In   a   n 


tvphoid-liacillns   has 


lieeii   asscicia 


t.v| 

ihoid-liacill 

nil 

her  ot'  otlu 

rt 

lis   was  oi)- 


r  eases  the 


till   with   the    ]tyoueiiie  encci   (Anton 


Fiitt 


ercr  '). 


In  a  ninnher  of  instai  ces  I  have  lieeii  alilc  to  deinoii- 


-Irate  the    pre-ence  of   sta) 


ilnlococcl    ( 


xehisivelv  ill  the   ,iiis  ohtai 


pnnetiirc  of  the  jjlaiul    diiriii!.''    life.      Kxccptionally,   I   iiavc   ohserveil 


arotitis  as  one  o 


f  the 


mntoiiis  of  a   eomiilicatinir  irenera 


iympt 


il   septi 


.Vlthuiiirii  earlier  writers  report  the  oh-crvation  ot'  this  occnrreiice  more 


fiei|iieiitly,  this  may  !.e  due  to  the  fact   that   tlii'  term   sept 


leeiiiia   was 


eiven  a  wider  interpretation   than   appears  justified   at   the  ]>reseiit  day. 
I  have  also  in  a  nninher  of  instances  seen  parotitis  as  the  sole  metastatic 


inanil'estation,  without  the  dcvi 
.11 


ipmeiit  of   ireiieral    pyemia,  partH'ula 
s  of  tvphoid  fever.      I   can  rec; 


tollowiiiLr  -ii])|>iir;itivc  I'literitis  in  eases  ot  ty| 

for   in-taiice,  haviiiir  oliserved  metastatic  aliseess  of  the  iiarotid  <rlanil 


■h 


la 


V/iiinh-.lniKilfii.  IMTiS. 


Cnitrnlhl.    f.   Jin,-/.,    liij.   xvil. 


M„„.h.  ,„r,l.    \\',.,h..   Isss,  N...   I'.l. 


L'dl 


rvriinii)  ii:vi:i;. 


•_'    cM-i"    tolli.wiiiL'    typlmid    ]» rity|ililiii-.      In     1     <<C    \]\v>i-    cases    tlio 
atVcrtidii   was  liilalii-al. 

Ill  L'i'iirral,  |iarolitis  i- ma' nf  ilic -cvirc  ami  daiiLr"  rmis  (•iiiii|jlicatiiiiis 
ut'  tviilmiil  t'lvcr.       Lirl)cniici-trr,    anient:  2  10  fatal  cax-  hctwccii   ISii") 
and    ISiiS,  iili-i  Tv.d   jiamtili.-  in  ti — '_'.>'  ["i-  ciii.     Of  tlic   H!  ca.-rs  ut' 
lianititis  r(]>(irttd  i>y    llolViiiaiiii,  U>  wliii'ii  nft  rciuf  lias  ]>r(\  ioiisly  lic<ii 
iiiadf,  death   (leeiiifed    ill    It.      (H'  'JS   cases   cdlleeted    liy    Keen,-  S  wefe 
i'atal.      Aiiii'iiir  llic  seficiiis  c(iiise(|iiciK'e-,  tliriiinlMi^i-.  of  the  jiiirnlar  vein 
and   the  <-ereliral    -inii-e>  and  acute  ediiiia  ot'  the  hraiii  aiv   ti>  he  nieil- 
timied.    A>  a  foiilt  (if  direct  (  xtcii-ioii  (.I'^tlic  -iiiipiirati m,  |ierii>-titis  and 
neeio-is  of  the  adjacent    liuiic--,  sii]i|iiiratiiin  ct'  the  niass-ters,  hiirrnwiiifj; 
<it'  the   |iii-  lictweeii    the  ^npcl'tii'ial   and  dee|i  t'a-ei;i'  (if  the   neck,  ill   the 
latter  e\ent    with     the   dev<'li>l>ineiit    f\'    iiiediastiiiiiis,    may   take    ])lace. 
Secniidarv  ]r.(niia  i>  a  |p(i— ihility  iindi  r  siieh  conditions.      In  1   instance 
I  (il)-erved  iiiriifalph'  facial  pal-y  (>ce  al-o  ( irie~siiiLni' and  Lieliefniei-tcr). 
Stomach  and  Esophagus. — Althonuh   it    i-  extfcmely  rare  that 
the  stomach  and  the  e>o]iliai;ii-  cxhiliit   s|-ecilic  alteration-,  and  almost 
never  trivc   rise   to  characteristic   syniptoins,  they   do,  especially   at    the 
iHL'iiiniiiji-  of  the  atuick,  ])lay  a  certain   rnf,.      it    will,   at  any  rate,   he 
well    to   de\(itc   a    few   Words   to   the  consideration    of  such  pneral  and 
indetinile    >yiii|>tonis   as   the    pain    in   the  e|)ii;astriiim,   the   liati^ca,  and 
the   voiiiitinii'.      Xerxdiis   individuals  t'rcijtiently  complain  of  a  sense  ot 
dull   prc--iire  in  the  e]>ipistrinm  from  the  ]irodroiiial  sta^rc  into  the  first 
week  of  the  di~ea-e.      This  s.'iisitioii  almost  iiever  attains  to  the  inteii- 
silv  of  the  doiiiiiiatiiiL''  paiii~.  --neli  as  are  cliaraeteristi<-  of  the  tirst  days 
of  other   infection-,  diseases,    particularly   variola.      Severe  ]iaiii    in    the 
epi<_'-astriiim,    therefore,   at    a    ]ieriiid    in   the    coiir-e  of    a   fehrile  disea-e 
when    the   diairn"~is    i-    nncertain    is   ajrainst    rather  than    in   favor   of 
tvplioid  fever.       I'^roiii  the   ^eeo!ld  week  on,  the  eoin))laint>  of  cpitrastric 
<ippre--ioii   yield   to   the   progressive   somnolence. 

Al-o,  voinitiiiL'  and  nausea  hy  no  means  jilay  the  rn/i  in  the  liej;iniiinfr 
of  tvphoid  tevcr  that  they  do  in  that  of  tyjihus  t'ever  and  variola.  I 
have  ohsc^rved  tlicin  iiio^t  frei|nciitly  at  the  l)e._riniiint:  of  the  disease  in 
ohildreii,  in  nervous  women  or  hy>terical  men  ;  hut  nmler  such  cirenm- 
stances  tliev  ajipcar  n-cncrally  as  a  transitory  t'catnre,  and  almost  never 
liecome  severelv  spasmodic  or  colicky.  in  some  instances  the  attacks 
of  vomitinji  ap]iearcd  not  to  he  induce<l  iiy  irritation  in  the  stomach, 
hut  hv  the  aii.:inose  lesions  previously  mentioned.      In    such   cases  they 

mav  1 intinncd  into  the  second  week.      S<.vere  and  iv|H'ate<l  voinitinjr 

at   the  heiirht   of  the  disease  should  siiirgcst  the  possjhility  of  certain 

'  IJ.'tkr.  Inn,,,,.  /);,s.~.,  Ua.-U-,  187U.  ''  !■'•■■  >'•'■ 


SYMI'TOMS  .\.\l>   <  iiMl'I.KWrinS^. 


20.') 


)iiii)li('atiiiii>,  such  :is   intiiiiii;i 


tis  ;iu(l  allicil 


Ihr 


IHl'lIllUltlS,   MIK 


I,  li 


'IKUllilIlS,    I 


latent  iiitf.-tiiial   lirinurrha).'-i 


icrt'(ii~iti"ii  oC 
Alter 


ive-eeiiee  and  (llinil;^  <•<>: 


invali's<'eiiee,  nausea  anil  voniitin^''  ai'e  alnin-l 
ivs  retel-al)le   to  dietetie  en-or.      Smie  writcfs  I'efer  to  tlie  oeeurreiict! 

lor 


il>l 


t    uneoiitfollable    voniitiii"'    duniij^    conNaleseem 


wliieli    no 


Miate  anatomic   basis  co 


mid    l>e  found  at    ant< 


j,sy. 


1 


.1)S<. 


C.1  tl 

cs    of 


lis   inanile>tation,  wliidi  I    hclic\c  to  li- 

pfotfacteil    coufsc    witli   severe   eorn|)li<'atioUs. 


■xtrcinciv  i-ari',  oiilv 


111    I 


iliicli    from    tile  oilier   ^vmptoms  was  to  he  coiisii 


leivd 


as   one   ot    iieiii- 


ric  typlioid,  I    tiiund  erosj 

■  anatoniii  cxiilaiiatioii   of  tiie  vomiting. 


astritis  with    numerous  ecehvnioses 


Tl 

staw. 


ic  a]>|iclite    is  w  I 


o-t    III  most   cases  as  earl V  as  the   prodromai 


d 


.11    d 


iiriiiir    die    first    wit'l 


lallellts 


aversion,  even 


a  distrust,  for  tin-  iiiirestioii  ot'  iiiod,  and  complain  of  a 


stale 


e,  i)asty, 


the  lieij;lit  of  the  d 


d  or   hitter  taste, 
iseas(>  tliesi' 


<1   of 


a   selist'   ot    I)1I"I1I11L 


tl 


iirst. 


-iihiective   manifestations  disappi 


At 
iiid 


the  patients  swallow  niechanicallv  what  i 


(tt(Te<l  them,  at  times,  it  is 


true,  with   some  resistance. 


II  a  won 


1,  d 


iirinir 


th 


1" 


and 


I  at  the  hcitiht  of  the  disease,  the  state  o 


I'lg 
most    infections    di 


f  th^ 


le  apiH'tit" 


'PI 


xl  of 
is  till 


I'voliition 


Tl 


diirinjr  the  jxTioil  of  involution  and 


coiKhtions    are 
ill  convalescence 


different,   however. 
In  children  and 


111  yonii};  at 
its 


hilts 


a  11 


larktHJ  almost  uncontrollahle  sense  of  hmiirer  niak( 


'I'l 


ipiM'arance  diirinir 


th. 


staiie 


it  steep  curves 


;.lderl 


y  |R'rsoii-   the  ap|H'tii( 


th 


In   nervous  women 
)tlier  hand,   treiierallv 


aiitinij  at  this  periiK 


1.      Dur 


rin^  convalescence,  however,  im])airmeiit  or 


ant  of  ap|M'tite  is  the  exception  in  all  patients.   Only  exceedingly 


sensi- 


tive in( 


lividi 


.1  tl 


lose  wlio  su 


tfcr  fr 


tl 


le  conseijuence 


ot  certain 


iplications  are  still  inditl'erei 


severe  con 

this  time.     Well  known  are  the  lar 


it   or  av<'rse  to  food  and  drink  at 


P' 


eves  witti  whK 


th 


.•h  tl 


lose  convalescent 


from  typhoid  fever  constantly  look  about  for  foinl  and  with  which  they 
tiillow  anyone  from  whom  they  hoix"  fultilnicnt  of  tlii-  control  I  iiifr 
<lesire.  The  ap|H'tite,  almost  always  ])rematiirely  large  in 
the  state  of  the  intestinal  lesion,  often  brinj^  the  ]ihy>ician 
with    the    patient  and    injudiciou 


I'lat 


ion  to 


111  con 


Hict 


clati 


r^ven    in 


th 


ihvsician 


th 


mav  be  a  striitrirle   between  the  sense  of  dutv  and  <onvictioii  and 


the   feelinji;  of  sympathy. 


I   recall  a  bov,  thirteen  years  old.  who,  diiriii 


LT  pri 


itracted  convalescenre 


from  an  attack  nf  tvphoid  fev  ■■.  was  jirovided  food  to  the  utmost  limit  of  the 


permissilile.   and 
inier  that    li 


I   then    re(|iiesle(l   his  sisters  to   come   to   hi; 


side  to   eat 


III 


slices  (if  bread  and   butter. 


It   at   least  be  able  to  see  them  dispose  of  tlieir  huge 


ill 


^L,-  .LI.-: 


•2^»; 


r)rii"Hi  I  i:vi:i:. 


1„  il„.  ,oii-i.lrnitint,  of  llic  :iMMl.M,iic  all.THion-  lvl\'IVM,r  w:,-  ina.l.' 
t,,  rrvVMn  o,-;,Mlr  I.H-M-  In  il"'  -in,na.-l,  that  aiv  .ti.-omitriv,!  in  .■a-c- 
,,f  tv|,li.,i,l  r.v.r.  rii.-r  a.v  -caivrK  attciulc.l  uill.  -l-.'.ial  rliin.al 
niaiiitr-tati<'n-. 

|i,„„.l,anl  aa.l  his  |mpil.  L.r.'n.l.v,'  liav  .all.Ml  atlcution  tn  llu;  fa.'l  llial 
tvhii..i,l  U.vrr  an.!  .lilalalion  ..f  ll.f  Mmuarl,  arr  .-n  trT.|U,i.;  Iv  a>MM-,al.Ml  llial 
.,  V,,,,,,  ..„„n..rli..„  iMlvs.vn  thr  t«.>  lunM  !„■  tlmilL'hl  .>!  I'.ylliol  thr>L. 
vM-il>.r.  hdi.'vr  nni  ,mlv  llial  .iila'alinn  of  tl...  Mmuarl,  ,„ay  1m.  ihr  ivMill  n 
,,,,|,.,„|  i;.v..,-,  Iml  aUu  that,  r„i,srrM.ly.  .xiMiML'  .lilalatmn  nt  lli.  HnaKuli 
,.,',„-  unhni.l  inlrrliou.  Tl,,-  tar.  il.al  in,' iv i.  1  Mai.  alla.lr,!  >r\.;ra  tniics 
l,v  ivplini.l  f,v.  I-  li-i'MUfiuiv  Mi!!.r  Imm  .lilalalim,  nf  tli.^  .-l.^inarii  i>  lliou-IH 
,„  |„.  .MK-iailv  .■onvinci.iL'.  S.,  far  a-  I  kwns.  iIhm-  Matcinrnl>  liavf  iHit 
_s,.,  I,..,.i,  roHli'nur.l  ii,  llu-  (i.ianan  lilrraliin'.  l'.i>o„allv,  tn.in  my  ..un 
",M.,  riiiK'c.   I    am    unalilr   1"   \fr\\\    llnan. 

l;,.f,.,, ■„.■,•  I.a.  alna.lv  Imtm  n.a.l.'  t..  tlic  Mi|..  liirial  .-n.Mnn.-  a>al  ul.vrs 
H.MK-.iiM.-s  .,vn  i„  llu-  ;-H.|,l,a^us  atu-r  d.-alh.  TIu-m-  ,-an-lv  ^.v.-  hm-  m 
-va.ptuM,..  In  111.-  rax-  nf  .  M,|,l,a-.-ul  ..l.-cralion  n-|,o,-tnl  l,y  Mih-lu-ll,-  Imu- 
,.\..|-  for  luo  .Imn.  l.-rni-.-  .l.-alh  tlu-.v  \v;i>  Nvrll-inarU.-l  .ly^phn-ia.  N-v.-ral 
.-a-r-^nf  ,-o|,l,a"'i-inns  ,luriM-  tvplii.i.l  U-v.-r  liav.-  lu-.-n  n-porh-.i.  I.lit  it  is  not 
known  wlu-tlu-r  .in-  has  anv  analoniic-  hasi..  No  .-as.-s  of  luanal.-im-sis  as.o- 
.•ial.-.l  Nvitli  .-.opha-j.al  l.-sions  have-  h.-.-n  r.-|.oi-U-.l.     N-vonil  rases  o|  stn.-tn.-e 


.,f  til.- ,->ophai:us  tollouinir  lypiu.i.i  f.-voi-   liavc  o.-,-\irn-.l 


Tliis  is  iisiiiillv  a 


laU-MM|n.-i.  I. lit   llu-  01IS.-1  of  >yinpton.s  may  l.i- .lurin-  c-onvak-sct-n.-f,  a.s  in 
the  i-aM-   rf]ioi-ttMl   liy   Sumim-rs. 

I^iver  and  Biliary  Passages.— Thr  !iv,-r  an-l  tlic  l.ili.iry  pas- 
sa-os  also  ,,lav  no  prominont  rnir  in  tlu- -nli-iaiy  ^yinptoinatulo-ry  of 
tviilioii!  f.-vor.'  K-i.o<-iallv  siil.i.-otivo  symi-toni-  n-t'oi-.M.-  to  tlKiii  arc 
,:xt,vi„olv  ran-.  ( )l.i.-.-tiv.-K ,  at  tl,.-  l,.-i,L^ht  uftlio  .li-.-aso,  tlio  n-.^ion  ot 
,1„.  livor  is  ,,,-oaMonallv  t.n.l.T  on  |m-s.iiiv,  a-HH-iat..!  witli  oiilai-.m.'nt 
„rtiio  OP-.U1,  n-nallv  of  iii.Klorat.-  -nnl.'  an.l  |.rol.al.ly  .l.u-  to  l.y|..-.vin.a 
ami  .-ioiMlv  ^wi-llii,-.  It  is  f.irtli.r  to  1..-  noto.l  that,  in  a  niajonty 
of  all,  ovon  H-vo,v.  ras,->  of  .yplM-i-l  thv.T.  |.rovi<iiiijr  tlit-v  arc  miconi- 
,,!ioato.l,  tin-  liv.-r  irt-ii.rallv  .loos  not  .-..ntiiuiou^ly  .■x.r.-.l  it>  nofn.al 
si/...  So  far  a-  i-  Ui.own,  tii.'  fo.-al  n.K.n.sos  pivvion-ly  n...nti.m...l  -ivo 
ris..  to  11(1  sviii|itoms. 

I.-t.-ri.-'i-.  in  th..  oi.inion  of  ni..st  ..xi...ri.-n.-.Kl  ..Iwrvcrs,  amoiifx 
Nvho.n  Miir.-lii~on,  (;ri..ssin,L'.>r,  an.l  i;i,-l,.-mi.-ist..r  may  ho  m.-ntion.-.l,  an 
,-l....iallv  ran.  .naiiif..stati..ii  in  tlm  .'.mrs.'  of  typh.^i.!  f.-vr— s..  rare 
that  s.,.n<.,  as.  for  inMan.-o.  Fi...ll..r,  with  n.f.T..n...'  t..  W.-ilV  .lis,.as..,  .-on- 
si.l.-r--  tliis  fa.-t  p,.,.i,..rlvof  si;rniti..anc..in.lim.r..ntial  .lia-n.'sis.  I'osMhly 
this  ,nanif..station,  wln.-h  is  .•,mu.i..n  in  son..'  ..tlmr  inf.-.'tions  <li>.as..s, 
an.l  th.-n  i.riii.-ii.allv  .lii<-  to  .liio.h-nal  .-atarrli,  is  s..  raiv  in  cast-s  ..f 
tvphoi.l   fcv.-r   l....ans..  in  ti.i-  .lis.-as..  th.-  ^t.mia.h  an.l  tlu-  npiM-r  p.-r- 

,  ..  „il,„„i„M  a-  lV.t..n,a,-  .-.  Ii.-.vn.  ,^  |,l,...l.-.  ■  .-t.-..   VV,,'.-.   I'ari^.  l^H.:. 

■-•  ./„/,».  Hu^^kiu.  11..,,.  Jirp..  v,.|,  viii  ■•  n.U,.  M.I.  Junr.,  O.i.  'JS,  1?W. 


SYMI'I'iMS     IN/'    I  iiMfl.U  A  imSS. 


'_'(I7 


Al-n 


.1'    tlir    illtr-lilir    illT    lull     little    IIIV 


:illul 


her-    ronditinii    tiiMirillL"    llic    devi  li>|) 


ll:      llic     lIliiriMll      pI'MCOS. 

II  III    lit'  icicrii*    ill    >ciiiif 


iiit(ctiiiii>   (liM'asi-,  IK1II1- 
.1 


■K     iii:irkc<l   ;iciili'   -williiii:'  of  the    |i:iriii(li\  ma 


I"   tlic    liver    ami    eoll-eelltive    llllcl'li  ilill  laf    In 


ar\   -la-i-,  i~   eiicipiin 


lerol 


uitll  eMI-eliie  ranlv    m  ea,-e-  ii 


I'    t\|il|oiil    te\er. 


I 

<Klrl 


|(  lieniiel-ler    i' 


li-er\.il    iaiiiiiliee    lull    -'ti    time-    ill    1  J'JIt   e:;>e-.,  aixl 


lia-     -eell     It    I'll 


.1 

I    ."i    liiiii-    ill    S^'ill   ea-e-. 


it-    |i-eilllelle\      -eelllT.    tii 


\arv    111   I 


litleiviil    elPlileiiili-,    a 


I-    !)a   (  usta,'    ill    IS'.IS,   i-e|,orti.l    '.   ea-e 


t'l'iiiii    the    rrnii-\  Uiiiiia 


ilo-nit: 


if   wlliell   lie   IkhI    -eell   W  itllill  a 


lliollt 


ll.-.        II.   -I 


la-  anaU/.eu  •> 


■1  i-A-v-  fnnii  tlie  liter  :iiir< 


11 


Ik    'irnhahle 


the    laiimliee    i:i    tlie-e   ( 


aM'~    Wefe  :    < 


:',  ;    el|(ilee\-t     1-,    •'>  ;    llli-ec 


-^.  ti  ;    aeiite    \ clluw 


atarrlial.    I  ;   |i\  lc|ililel)iiis, 
atrn|ili_\ ,    .")  ;    |o\ie,    -J  i 


illieel'Iaili,     i. 


Aeei.nliiitr  In  (  )-ler,    the  i"i-e 


it'  jailliuiee  iMMi 


nriii'j-  ill  tv|phiiiil  text 


av  III'  !^riiiipe<l  ill   fmii-  eali 


irie.-.  :   (1)  eatari-lial  ;   ( 'Jj  tnxie  ;   (.'Ij  tlmst,' 


a-.-(iei 


Iteil     witl 


(I)  tl 


a^M>eiatt 


il     with    'rall-stdiies    ami 


lidlaiiiiili^. 


Catarrhal  Jaundice.— <  )-ler  think-  th;it  the  -lidit  jaiiiKl 


lee    III 


ea-es  of  inouel'ate    -exei'itv    1-^ 


till-   loriii,  ami   iiiKler   tin-   lieaili 


liiiir  II 


inelmle-  l> 


the  S  c'ase-  re] 


I-ejMirteii  liv   llllll. 


Da  Co-ta,  i 


idwever, 


thinks 


lliat    inii-I  of  the  eax 
•'i_'  ea^es   iindei'  the  ea 


s  are  of  toxii'  onii'iii,  a 


-  he  ilielmles    onlv  4  of  till 


tarrhal.      It  i>  intere-tinjr,  in  this  eoiimetion,  that 


•lav-eolorc<l  -tools  afe  of  rafe  ocelivrenee. 


TheN-  were  not   elav  eolofiHl 


\  (if  the   ■">   ease-    feportei 


"IM'S    is    the    |)l'eseliee   of    elay- 
iKlllv  of  these  inililef  cases  liel 


I  liv  Da  <'osta,  ami  in  only  1  of  Oslef's 
colored  >t()ol-  inentiiined.  In  favor  of 
iiiT  of  catarrhal,  ohstrnetive  orijriii   is  the 


■riv;it    freiineney  witli    which    the   haeilli    arc   pre-eiit    in 

quite  constant  occurrence  of  t\  iihoid-hacilli  ii 

of  experimental  ini«iilatioii-ty])hoid  in  ralihits  wa 

in    1S!I 


the   liile.      The 


I  the  irall-hladder  in  cases 


lied  1)V  Hlachstcin 


1.      After  (iill)ert   and   Cimdc'   had   demonstrated  the  typlioid- 
hacilli   in   the  hiiinan  ^'all-hhiddcr,  C'hiari "  showed  the  almost  constant 
f   the    haeilhis    of    KlHTtli   in  the  irall-hhidder — in   'JO  of 
hers.      Chiari'-  ohMTvations  have 


oceiirri'iicc    o 


I'l  autopsic: 


olteii  in  cnorniuiis  mini 


liceii  lonlirined  hy  IJirch-Hirsehi'ehP  and  others.      In  most  c-ases  they 
cause    no   damafre    to  the   eall-Madder  or  ducts.      That    they   ])rohahly 


initiicc  more  si 


vere  forms  of  iiitlamination  an 


'    Trnils.   ■,/    Ass,..-     Am.    I'hfis..    Vol.    \iv. 
3  ./../.».s   II,.J'kll,s   /In.y,.    /{,•/,..    V..1.    viii. 

'  J.,/,„s  llupl,i„s  ll.'s,,.  Hull..  IS'.H.  v,.l,  ii. 


1  mav  h'ad  to  the  foriiia- 
»  //-;./.,  v.il.  xiii. 


'^Se,r.  iiufl..   Is'.ili.   Nci.  ■>><.  iinil  r,,ti,j,l 

<•  r,;,,,.  n.'-.L    Wn.-h..  IS'.i:;.  N"..    -j-j, 

'  I'iith.  Aunt..  Ikl.  ii..  -1.  .Null.,  S.  H!t4. 


„/.  .le  la  .M,,-.  bwl..  ISIH,  N,..  11. 


TYI'llnlh    I  IVF.i:. 


1^ 


li(i||  111'  ciilculi  will  111-  -|iiik(ii  III'  l;i((i'.  \\  liillur  llnv  i:ili  ihildrf  .i 
mill!  riinu  ill'  lalarrli  nl'  tin-  ilml-,  ami  -n  lead  In  an  nli-tniitivc  cataialial 
jaiiiiiliif,  i-  iml  yil  <i«  I'mitfly  -iilliil.  A-  «<■  know,  liii\\c\  ir,  Imw  ihc 
|iir-iiicc  111'  l\  |iliiiiil-l)aialli  ill  llii'  iiriiir  nay  ;:l\i'  I'i-r  tu  llir  inililc-I 
I'liriii  ill'  i\ -liti-.  a-  >liii\Mi  iiiily  liy  llir  |iri-i'iii  r  ul'  a  li  \\  |)ii— nil-  in 
llir  lirilic,  a>  Well  a-  In  llir  liinlc  -(Aclr  uraili-  nl'  i\-lili>,  it  -rilll> 
iii'iilialilr  llial  a  ^iniilar  ciiiidiliiiM  can  occiii'  willi  i'('L'';n'il  I"  llii'  liili',  anil 
lliai  a  -inijilr  .alairlial  inllaininatimi  'nay  he  xl  u;i  tlial  iniiiicc-  ilioc 
niililcr  i^iailc-  nl'  jaumlirc. 

Toxic  Jaundice. — In  t'a.nriir  tlir  view  tliat  many  of  \\v  ca-i'- 
aiv  111'  llii-  liirni,  Da  (n-la  inc-i  lit-  llir-r  aii:Mnicnl>  :  "It-  m  rniriiici', 
as  a  rnlf,  a- a  laic  >\ni|iliini  ami  in  i;i';i\c  ca-c- ;  tlic  cliaraclcr  nt'  the 
-tiiiil-,  wliicli  aiv  1)1.  little  iiiiiditiiil  ;  the  ecnci-al  -iniilarity  tu  the 
jaiimlicc  miticcd  in  nther  inrcclivc  ili-ea>e-  and  altered  lilund  -late-, 
-iieli  a>  in  |>veMiia.  The  cnnditinn  nl'  the  li\er  it-ell'  diie>  nut  ;^i\i'  lis 
niueh  int'nnnatinii.  Yet  where  the  nri;aii  ha-  l>e(  n  careriilly  c.xaiiiincd, 
it  has  licell  rnlind  In  slinW  deu'cneinitinll  nl'  the  li\tr-eells  that  has  lieell 
likened  l)V  l'"i'eriehs  even  tn  the  state  I'liinKl  in  acute  yelhiw  atrnpliy." 
yiieh  a  ca-e,  runnine  a  eniir-e  like  aeiile  yellow  atl'ii|iliy,  with,  at 
aiitniisv,  a  lisev  fc-cinliliii!.''  that  I'niind  in  that  enmlilinn,  has  lieeii  lately 
reimrted  liv  Saiiliniin.  Ket'ereiice  has  al-n  Keen  made  to  this  cnnditioil 
hv  (iriessineer,  |,iel)eniieister,  and  1  InlVinaiiii.  When  this  rafe  ('"li- 
ditini:  uccni's  at  all — 1  am  imramiliar  with  it  I'lnm  |)ersniial  nhsefva- 
tiiii, — it  is  said  tn  a]>|iear  at  the  heiirht  nl'  the  ty|ihiiid  |irnee— ,  at  times 
in  assiieiatinii  with  di-timt  paiiit'il  tiimetiictinn,  and  then  ra|>idly  pro- 
irres-iw  <liminiitinii  in  the  si/e  nt'  the  liver.  .laiindiee  sikhi  a|i|iears, 
tup'tlier  with  heinnrrhaL^-  f'i'"m  varimis  m-jrans,  lieinaturia  and  alhu- 
miiiiiiia,   cardiac   weakness,   and   death    in   cnina 

Abscess  of  the  lyiver. —  I>a  Cn-ta  ha-  enllected  -l-l  cases  in 
which  the  assnciatimi  nf  ali-ce-s  nt'  the  liver  with  ty|ihnid  fever  seeiiUKl 
k'Vnnd  doiiht.  Of  these,  mily  7  had  jaundice,  lint  in  I'J  it  i-  not  men- 
tinned  at  all.  I  knnw  nt'  im  ease-  in  which  the  aliscesses  are  due  tn  a 
hx'ali/aliun  of  the  tyiihnid-hacilli  in  the  liver.  Ali-cess  nf  the  liver 
mav  arise  in  three  dilfereiit  ways:  (I  )  .\-  niie  of  the  manifestatinns  of 
p'lieral  secniidarv  se|)ticeniia  nr  ])yeniia  enm|)li<'atiiitr  ty|)lini(l  fever;  ['!) 
as  a  result  of  septic  pyletliromhnsi-,  in  comieetinn  with  siippiinitive 
atl'eetinns  nf  the  intestine,  e-pecially  the  cei'iim  :  linally,  (■".)  in  cnn-e- 
cpience  nf  varinii-  inllammatnry  and  ulcerative  iirncesses  in  the  larjrc 
hiliarv    jias-atfe-   and    the   jrall-liladdcr. 

[  have  p<rsiiiiallv  oli.served  instaiK'cs  nf  all  three  inodes   of  orifrin.      An 
instance  of  the  first  varietv  ciinsist.s  in  the  ca^e  of  a  iiiaii,  twenty-three  years 


M  U/'/".l/v     I.V/'    <  oMflK  .\  ri'iSS. 


209 


ill    llic    n 
in. I     li..l.-n 
Clivii-lrk.     ihr  I'. 


Iniiii 


lllc    >i/.i'    of    M    liiLrriili'-    lo     iIkiI    (I     :i 


:hi     mIm-  .,f  ilic  li 


\IT.   ililll 


lllll-,-     iluf     In     ;i     '1' 


A  -Imihir    ("ii'lilinii    li:i-    hiin    i.li-ciAi 


i'|p|\      Ull'lcl'- 

,1  l,\    l,..ui-' 


riiicr  111  II 


.1     .-U|i|HI|-.IIIM-     I 


l;ill(|-  alicr  |irii'lLciiii||-ilis  lit'  iIh-  l;ir\ii\.      <  >.-lci-  liM>  l(|>i 


Wllll'll,    III    III 
till'     {llll'niiil 

lilii''-:ili-if>-i 


Milinii  In  ilic  al'-ii'.-.-  "I    ill.'  h\ri.  linn 


lllllllll.-.   Mini     Ilic 
I    -Ucll  :l  r;l.-i',    In 


-ll|l|llll':il|n|l     III 


:l,-inil,  :iliH.'>;.  1  I    liir    .'MMn.lici.alir   lyiii|ili-L'-laiiil.-.  ami  iiiullil'l' 
■a>r.-  l.iioiiLiiiiir  ill  llii-  Ml  I II II I  rali-L;iii  V.  I  lit 


I  li 


lii>l.  ill  1"<'^7.  ill  |iiivali'  pru'lir'.       In   llii-   cav  an  a 


liM  l>.~    lIcVl'llllil  ll    111    ill 


ri'.'lit  iliac  lii-s,i  a-  a  >ci|iiciicc  nf  t\  |.lii.iil   pi 
an    irrcirnliir.  lniLiiiLC   uIpmcss.  a-    lari;c  a.-   a 


nlv|ililili.-.  nil 


I   it 


a|i|ilc.  in  till    Icl'l    liilic 


avc   n.-c  III 


il    Ihc 


liver,  aitciiilcil  w 


illi  chills  mill   rliaracicii>tic    ii 


Icriinllciit    tcvir,  ami  Icnni- 


natiiiL'  liiliilh 
wise  nrii'lna 


ll 

tc.l    tVll 


ic  sccoii'l  case,  iimmi 


ricil  Iriiin  iiiv  clinic  li\ 


Knllll 


hil:.    like- 


ii|i|iiiralivc    |icrily|ilililis.  ihhI   ;:a 


vc   n.-c   Id   iiiiiI1I|i 


o.-cs  111'  llic   liver  III  till 


ilistriliiilion   ol'  the  im 


tal   Vein.        Haclelinloiiic 


iiiiiiialidii   ili<clii>e.|    ilie   |ireseii )t"  >la|iliy 


•i   (iiilv,  anil   no   l\  | 


liacilli.  III  tlic  nils. 


Klel.s' 


rteil   llic  liisl   inslancc  nf  ilic 


IcVcloplllell 


t    nl    illisci 


iias    |iriil)al)lv  rcpn 

he  liver  froiii  iijcci-alinii  of  ihc  hiliary  |pa.-.-a,L'e- 


ca-e  miller  iiiv  nhservalnin  neeiirreil  in  a  uninai 


1.  eii;lileeii  vears  old.  «itli 


an  cncaiisiilatci 


ilisecss   at    the   ^i.le  nf,  ami  lieliiml.  I  he  L'all-lihiiliier.  wliieji 

it'  a    piLi-cnll's  CLIL'  ilitn  llic  sllll- 


ninicatcil  willi  ll.  eXlcMilniL'    in    Ilie   size 


1     I  he    liver. 


stance  o 

lA'  the   l'niirt!i    wci 


lie    ciimlilinii 


hail 


ilevelnp( 


ll    al    tli< 


iniciiceinent 


k   it(    the   alt 


lick    >>{   tviiliiiiil    U- 


anil,    what    niailc   the 


lliaL'llnSIS    inn: 


t  ■litfieiilt.  it  was  at   the   licL'iniiiiii:   unattcmleil   with    |aumlic.'. 


iiml    later   was   att-mlcij    with   Imt   sliirhl    laiimlice. 

The  typhoid  inflammatory  affections  of  the  gall-bladder 
and  large  biliary  passaj 


tliiiripiie-ii  ciinsii 


ilci'ati 


Sllcil  ciccliri'Cllce--   Were   melltH  illci 


1  liv  Aiiilial,  l,iiiiis.  .Iciiiicr.  am'  I,einict, 
ami  siil)S(M|iientlv  were  de-crihed,  specially  liy  ItoUitaii-ky,  as  (li|iliflicric 
atlcctiiiiis  lit'  tlif  ;,fall-l)la(l<lci-.  Later  ( icrmaii  ami  l'"fciicli  writers  alx) 
refer  to  tlit'in,  i^ciierally  as  ulcerative  |iscii(liiimiiiliraiioiis  atlictioiis, 
leriiiiiiatiTi<r  in  al>»ce-s  of  tile  liver.  |ierfiirative  |Mi-itoiiiti>,  etc.  ( 'Imle- 
fv-iitis  ami  cliolaiiiritis  in  ty|i!ioi(l  tever  have  liccii  nioie  liilly  trcaleil  of 
ill  tlic  p:i-t  few  years  liy  Osier,'  Mason,'''  Da  Costa,"  ( 'aniac,'  I{y>ka."  ami 


(illler- 


Th 


nitliors   liavi 


tell   ami  rctiortcd  iiiiineroiis  i:i-es   in 


lllicli    these    comlitiolis    occurred    eitl 


^■1 

ler   as   eoiii|)lieatioiis  or  as  ~e(|iicl 


As  to  the  frc(|iiencv  of  aciit< 


ilccvstiti-  diiriiin-  tlic  fehrile  attack,  m> 


considerable  >tatistics  have  liecii  collected,  althoiinlM|nite  ininieroiis  cases 
have   licen   rei>orted    hy  the   ahove-incntioiied  writers,      \\'ith    I'eirard    to 

'  /,.-.-.  ,-,/.,   isjl.  .M  ,,1.,  v,.|,  i.  '  .1'/,,,    \V.,„.  ,„,,/.  /.;/,,  isci;.  N...  :!7. 

'   /.'.;■///(,     l:r,,K     ir..7,    .    IS'.lll.    N,,,    i|        Tlli-    Mllirlr    r.int;iiii-    nil     IXtlll-ivc    liit.lin<;- 
Riphy.       lit'   -illlil;ir  r;i-|.-.    tlien^    IIIV    ritiil    lillll    .if   TuM'.'.l,     h'Ini     MfHhrll  .    Illlln  luir!:, 

isiij    lSi,:i;    iliMl   .if  .\.,1l   II,,-i;„.    I.I,„.    \y.,.l,.   l^S-J,   N...  .'il  :   iiiul   that   et'  I'.m  kliiis;. 

iinvi.  /);,«..  n.Tiin,  isiis, 

<  ll.,„./h.„-/,  ,/,,/«'/,.  .[„„/.  isi;s.  ,,.  -iMi, 

■>  /,...■.   ,;t.  '■   Tr.i,.^.    A-^.^r.    .\„i.    l-hiis..    v-l     \ii 

'   /..„■.   ,-it.  '  ./..liHS   II. ;,/.;„■.   lis,,.    R,/,..    VmI,    \iii. 

»  Mni.-h.  n.r.l.   ir../,,,   lid.  hi..   N...  L':!. 
14 


210 


7  1  /■//"//.   /  /  1  /  /;. 


it\ 


llir  ilin|,":\  ,  it  Mi:i\  Im  -:iiiI  1 1 1.1 !  Ill  :i  liiiliiiirr  (iT  liir  ,:i-(-  ill  w  iiii-li  ii:ic- 
t.  rinli.i;!!'  i\;iliiill:ili..|i-  Uiiv  lii.iii.',  |iini'  iilllilii-  "''  iIm'  I  \  pin  lii  I-I  i.i.  il  In- 
\\(  re  nliMiiicil.        Hill,  :i-  iVoiii   till'  \v..|k   ..I    (    lii;ili  ;i1iil  miIk  r-,  iIk    :i1iiiii-| 

, -i:i:ii     |,iv-.iici     ..r    llic     |\  |i|Mii(|-li:i(illi    In    llii-    i:;ill-lil:iilili  r    li;i-    l"i|i 

i|.  ni..n-lr:ili  il.  llirii  iiin-l  lir  -..mi'  -.  (  i.ndiiiv  linl'T.  Ilircnl  -linlir-. 
|.:i\.'  nn  iloiilii  ili.ii  :^:ill--l..iii  -  iviiili  r  the  liili:ii\  ilinl-  .111(1  liiill -Miiilili  r 
iii'in-  live  iiliv  !■  |..  inlri'liMn.       I'liil    wliili    -|..n'-  li:i\i    Imiii   IhiiihI    in   -Mnir 

(.1'    ill!-.'    ilclllc     r;i-.  -,    ill     llir     lli:iiMlil\     tll(\     ll:l\(       lie. I     ImiII    |irr-(nl.        (  >!' 

7  1    ca-r-    ..r  l.ili,ir\    inlivli ■..llni,.!    I.\     l\((ii,  in    .".^    in.   l:.i!I--Ii"ii - 

\M  IV    riiiinil.       Ill    .'.I    ili'ilv.v -mi-.   1  ni|i\  (  ni:i.  "I-  n!c  M  liiiii.n    «:i-    |.ic-(iii 

\\ill I     :j,i1I--|..ii. -,  :in.l   liMiii    II    I  lie  I  \  |ili..lil-li;icil  In-   w  :i-    i-.il;iliil.       It 

i-  |,r,,l.;il,|c-  lli.il  in  in:in\  r:i-,  -  ili<  .|i-iinri|oii  i..  ilir  tl..^  nf  Im!.'  i-  iliiv 
I,,    niiiiii- ;    llic    ijinuih    (,r    ilii     l.:Ml(ii.i    Imiiil:     llin-    r.i\'.|vi|.    :in    iiciilc 

ill||;ilillii;ili r    llii     Willi-    "i    llir    -:ill-l'l:i'l'l'l     m.i^    I"     llicliKv.l,    Iciililli: 

til  -ii|i|iin-:iliiin.  cli-li  nlimi,  |Mi--ilil\    nli  i  i;il  i.  .ii  mihI   |ii  rti  iiiil  I"|i. 

'I'lir  niiiin   -\  nilili.in-  III'  rhnlivv -lili-  nil     Iniiili/nl    |i:iiii    :iiiil    limlir- 

III—    ;in'l  ill'    |iri  -iiii  V  ..I'  ;i   ini '.        Tin     liinuT  i-  ii-i,.ill\    li.r:ilril   in  llir 

ri-lii  li\  |i..ili.ini|iiiini.  Km  iii:i\  In-  hhhIi  Imsmi.  imii  \n\n\\  tin  nniliili- 
,-[\~.  .I.niiiilirr  ni:i\-  niriii'.  Iiiil  i-  li\  II"  1111:111-  ii.ii-l.inl.  I'iiiiIhI-  :iiii1 
nil, IV  riiin|i|.li  iili-ii\:iliiin-  :i-  111  lln-  liiliiivinr  "!'  ill''  linLi"\li-  :iiv 
niiii.il.  Siir-ii'il  Iniiiti  iTiiiv  ill  llii-i'  I'.'i-i-  \\  ill  '"■  nl'iii'l  I"  in  lin' 
i-|i;i|il' r  nil  'rriiiliiH  III. 

Sii|i|iiir;ili\c  rli"liv\ -tili-  mill  iIh 'lilil  lii;i-i-  fcllnw  iii',:  ivplii'id  tivir 
;irr  n.inliiii.n-  ivi|niriiiLi  -iir'jii-;il  livninu  iil.  :inil  rnrtlirr  n.n-iili  r:itii'ii  i.-; 
Mill     ]ii.— ililr    lirlT. 

Till-  ivlitii.ii  iifiyi.liiiii!-l':ii-illi  t'l  till'  ti.tnrirn.li"t'{?all-StonCS  i- an 
(•xivfill.i'^lv  iiiti  ri'-liii'^i  iilir.  Uirliaril-'in  '  li:i-  -li"\vii  tli.il  llir  liinilli 
an  lVn|iiriillv  i!iini|iiil  in  iIh'  I'il''.  ami  In  ,  <  n-liiii'^.  ami  "llni-  lirliiAc 
ll,;it  llir-r  i'liini|i-  I'l'ini  llh'  iinrlci  fill-  -l"ii<-.  i'li'in  tlir  iiitvri'T  lit' 
-ti.iii-    tlir  I\  |ili"i'l-l>-i'-illi    li.iv  liivii    i-"lal'il    ilia   nninlirr  i.f   in-laiicc-, 

:iii<l  till-  v\|ii!iiiiiiital  |iriMliii-liiiii  uf  -all--l -  li>   iniMiilalinii  nl'  I\  plmii!- 

Ji:ii-i!li    intii    tlir    -all-Maililcr  i.r  animal-    !ia-    Ihvii    -iinv-riill\    ai-i - 

|ili-liii|  li\    (  iillui't  .111(1   l'""nrniir. '  liirliaril-uii.'  (  ii-liiiii;. '  and  dlirr-. 

It    ||;i-  liirii  ilcni'iii-tralnl  llial    ty  |ili"iil -liarilli   in.ay   ivinaiii  \ialilc  ill 
tlir  -all-l'lai|i|rr  t^r  \rai--.       Ilniiin  r'    lia-  n  pnrtnl  a  r:i-r  of  -ii|)|iiirali\c 

rlli,lrr\-titi-    iirrliri-ill'.'    ri'jiltivll     \rar-    .'iriir     tlic   atl.ack    el'    ty|llli'i(i    trvir. 

tV'iin  llir  |iii-  111'  wliiili  tlir  l\  pill. iil-liarilln-  \'.a-  i-ulalni   ill   pniv  niltiirr. 

Ii'rti  1-1  lire    iia-    !»(  n    lliadr    in    tlir   analnlllir    -rrlinll    tu    llir   (•i.llditii'll    (it 


»  C,m,jd.  ,■'„,/.  ./,-  1,1  ■•■■■■.  '"■-'..  Oit.  ;ili.  1>-'.i7.  '  / '•'■'.  ■>  /.'■■■.  ■■■'. 

«  ./../,„-•  Il.pl.n.s  11'  yr    /;.///..   vol.    V. 


M   '//'/"'/>      IN /I    '  "  1//7  /(    I  7/o\\. 


311 


ill,  1,||.>  ii-,ir.  'I'lii-  i-  known  |..  1m-  lliinn.r,  lii:lilir  in  rMl,,f,  :in<i  <>( 
|m«i  r  -|i.(ilii'  '.'niN  ii\  ( If.. in  l'"ln  |..  PMil,  :i-  cniM|i:iivil  «  iili  tin-  ii..rni:il, 
|n_'i;  |(>   ln:',il,    i',i-..ii;iii|i  I  ).       Wilh  iv.^;i|-.|  \<>  ihc  inllm  n.c  ..I' tlii-  :illi|-:i- 

tinii  II  III  III  I  111   mil  -liiLiI  riinliiil-  Miiil  till'  n|-iiii lliiii;^  "I  :i  ilr'iiiili-  iiiiliil'c 

i«    kii.iun.       l'..--ililv  ill.'    -irikiii^:    |i;ill.ir   <ii-  imh    iIh'   iiliin-l  .   .in|ilitc 

,|,.,.|.li.|-i/;ili r  till-  -tiiiiU,  i.r  iMll-iili|-;ililr  ilil|-:ili..ii,  :i-   I    liiiM'  nli-i  lAnl, 

iii;iv  Im-  i|.|Miiiliiil  ii|)iiii  lli:il  ciiiiililiiin.  'I'lii'  inliniMlr  rnmiiili.ni 
Ihiw.rii  iir..liiliiiuri;i  '  ui'iiiniii;:  in  i';i-i~  ni'  l\|ilioi(l  tr\ir,  wliii'li  li;i~.  :i.s 
v,i,  l„vii  lull  iilll.'  -imliiil.  iiii.i  till-  all!  iMlii.ii-  in  lln'  I'll'-  ainl  llic 
t'liiirli.iii-  iif  llic  li\ir  ill  iiciHT.il,  i-  :i  iiiallii-  fur  fiiliirc  in\c-lii:atiiiii. 
Symptoms  Referable  to  the  Intestinal  Tract. —  I'll.   in.  \- 

|i.|-lriii»ii  oli-.i'\cr  i-  liUi-iy  |.i  .■i—niin'  an  inliiual.'  n  lali..ti,  ami.  .a.'II  as 
t.i  il.lail-,  an  arlnal  |ialMll.li-iii,  l.i'lwriii  ill.'  rnii-|iirnMii-  -iM.ilir  all. Ta- 
li,,ii~    in    llir    inl.-linr   an. I    ll lini.'il     nianili-lalinii-.        I'ni-    may    l>f 

c.iiT.'.l  wilh    ivuar'l    I M  lin    l''-~    .■■.iiiiii. 'ii    "f  -iil».riliiiaii'  I'.m.lil i. 'ii-. 

A-  I.)  ill.'  -I'Vi  rilv.  till-  I'M.'iil,    iii'l    ill.'    I.  "'a  I  i/  III' f  ill.'  ii-iial   I\  [iliui.l 

li-i.in  ..r  llir  iiili'-liiH',  liuM'Vi'i',  iiM~I  --.mmI  ..l.-i  r\.'i'-,  I  liili.'Vr,  aui-i'.' 
ihal    ill.'  -lai:'.'-  I.r  llii'  .li-.'i~.'    |)|-..l(al)lv  .'i.ri'i'~|M .inl    in  ;^rii.'ral  willi    llic 

.Mi'iiriTii.'.'  ami  ill.'  ili'V.'|i>|ini.'nI  ..fill.'  I.'~i.>ii,  lull  llial  tlii-  i-  l.y  i aiis 

Irii.'  ill'  till'  .'liara.'i.r  ..!'  ill.'  in  inll'.-Ialii.n-,  ill.'  ~.'\i  rily  ami  llic  ilnrali.'ii 
..r  ill.'  alMl'.iiiinal  -ym|il.iin~  in  .I'l  lil.  Kvi'y  .'\|i»-i-ii'ii.'i'.l  |iliy-ii'iaii  "  ill 
I'l'i-all  wilkiii',;  I'a-.'-  ..t'  tv|)li.ii.l  l'.'\'.'r,  witli  -li^lil  '.'■'iii'ral  -yni|il.iiii-, 
willi.iiil  in.'I.  .iri-ni,  wilh. ml  al>.l,iminal  |>ain,  ami  willi.nit  .liai'i'li.'.i,  thai 
Li'iiiiiialiil  lalalK  t'l.un  iim'\|i.'i'l.'.l  inl.'-tinal  h.iiHirrha^.' <ir  |i('rt.irati\i' 
ii.ril'i  ii~,  ami  ."'.'a-iiiiii'.  I  -iirpri-.'  mi  anal.nni.'  .'xaininali.ni  ..ii  ac.'.iiint 
III'  ill.'  iinii-iial  ('M.'iit  ami  ^'M-rity  ..f  llic  ly|ih..i.i  intc-linal  j.'-iuii-.  ( '..n- 
\i  I'-.'U.  |)i'..t'ii-i'  iliarrhra  an.!  ..ih.r  inl.'-I  iii.'il  >vni|it.irn-  ir.'  iml  ran'  in 
ill.' carh.'sl  stai;.'-,  wh.ii  llic  -|i.'i'iti.'  inlc-linal  Ic-  n  lia'^  -.'ari'.'ly  li.':j;iin 
t.i  il.'\  i'l.i|>.  lOvi'i'v  .'ypiTii'ii.-cii  |)li\  si.'i.'in  will  kii'iw  ..I  ca-c-  in'i'-ciilitiix 
|.r.'|MiniiiaiiI  iiil.'-iiiial  -ym|iliiin-  ihf'.iiiLihiiiil  uhi.'harc  in  niiiaikahic 
(■iintra-t    wilh    ih.'   A\ii\a    anal.nni.'   Ic-i.in-    liniii.!   al    aiil.i|)-y. 

I  "hall  never  I'iii-l:.'!  a  eas.'  sei'ii  in  .'.iii>iillalieii.  A  v.iiiir.'  w.iiiiaii  .lio'l 
:\I  ihe  h.'-iiiniiiL'-  i.l'  ill.'  lliinl  w.'.-k  nf  ail  atlaek  el'  I\|.li.iiil  t'evcr.  Sli.'  liii.l 
mil  li.'cii  i'.)iu|)ell('.l  I.I  L'li  t;i  hi'l  niilil  five  .lavs  lict'.ii'.'  il.'alh,  ami  as  lale  lis 
a  week  |in'vi.iiisl v  liail  <|i.'iit  .'iiiisi'li'i-nhle  linii'  at  an  cviniiiL'  I'liIPrlainiiicnt 
uillinul  sp.'.'i.'il  iiii'iiiivcni.  n.'c.  I)in-iiiLr  tli.'  llircf  weeks  |ireee.liii'_'  .l.'alli 
tlu'i'e  liii'l  lieeii  (iiilv  variahle.  L'l'mTal Iv  iliiiiiiii^lie.l,  ajipelil.'  aii.l  im  .liarrli.'a, 
hill  rallii'i-  i',iiisti|iali..ii.  Marke.l  t'ehrile  niMiiit'.'stiili.nis  lia.l  he.'ii  nul.'.l  mily 
'liii'iie_'  the  lasl  six  .kivs.  r.isl-m.irlem  ('xainiiialiiiii  ili>.'l.is.'il  inl.'slinal 
i\|ili.ii.l  lesions  ihpiiiL'liiMit  an  exlenl  thai  F  hav.'  rar.'lv -iiM'.- ..hs.Tve.l.  In 
ihi-  l.iwi'i-  lu.i-lliinls  III'  til.'  ili'iim  aliiinst  all  ..f  i'.'Ver's  pai'lii-s  u.  r.'  iiifil- 
irale.i    in  part  ciinthieiil,  ami  in  I lu' ~ta'.'e  ..f  .'Xt'.iliali.in  .)t' the  sl.iiiLrlis  ;  while 

'  Ti-i.'i',  77,.  ~.'.  r.'ii'i-.  \'*:'0. 


'^•^ 


{ 
i 

V    J, 
1 

21; 


71  rii"ii>  I  n  1 1: 


i„  ,1,..  .v'i.m  of  tl„-  il.o,-..,.al  ^:.K.•  nuA   ihr  r.v.i,,,  n-.lt   tl.rrr  «M.  ><  .r-vly 

..     |,v..     ;„v.-,     nl      , U-     MHlnlMM,,..    MH.I      ll,.U,.|..r     ILimI     ■  •!      IIm'      I.TLfr     IhU-H- 

,l„,   ,|,,i,„K    ||,i,.,l     l,\    1,  iiliruhir    uhii-.    in    |'i 1     uiiu-iKil 

„     ,,.   i|„.    I,  -ill-  i.r    111!    :in|..|.-.    nil    III.     Ullr  ot    a 


n  1 H '    ^^  •  1  - 

M/..'.      >lill    iiimr    -iir|.n-iii.  ,       ,       ,         ,     ■ 

,.l,VMi-KMi.  »l,M.|,|.nvulU  l,:„l,l,...l.  in  llH...|,i,iiuMulll.rliu.limi.l.  mn„iM- 
:.,i;.M,v..|  |..il,.r:ill..,i  Ml  ai,  ul,  .  r  ..I  I  li  —  l-MiMrli  «  iiIimmI  pnAinu-  ,„.t..«..rll,> 
.\„i, U-.      1.1    111'-   '■'-'•   :'l-"   I'"     l.-i"i-"l    '.M''"'"'    "■^","'    ll'.-'  ;'='V'"< 


.Alnllal t     III!'    -I'lllJi-    '■^<l''-     i"'ll' 


I,    hki  \M-r    »illl     1  Ml  ll-inll    I'f    111'-     llllf'^ 


.iiiiiai 1    1  111       - ,      ,      I 

,,„al    l.-i r.M,    111.    s:iK.-    n|,    U.    ll. Ml.     nl    lli.     il.  uin.       I'.iuli    ii-nl 

iv-iill,-,l    In. Ill    |..  rl-i:iii"ii   "I    ll"     M  iniil'.iii |..iMii\. 

I,  uill  I"'  -i.n.  lli.i.i.'i'.  lli-il  il  i-l"ll.r  1..  -iM.l\  ra.li  .'a-.'  iii.li- 
vi,l,iall>    a. 1.1    I.,    n-rv.     a    ,l..,-i..ii    tliai,    |..    |.r.-..'l    ii|-ii    -li.  Mi.ni-' 

liii.  -.  ,  . 

\\,  -hall  iMtiiii  111,'  .li-.U"i..n  ..!■  111.-  imliv  i.lnal  liil. -llnal  iiiamlr- 
tati..M-  uiil.  racteorism.  Mans,  i-ailLiilail^  ..l.l.r,  «"rk-  .untain 
,|,-,ii,,li..ii-   ..f  th.-  rail>   ..li-.I,..r  iIm-   -.a.iH>   aii.l    ll..'    IV..,!!.  ii.s .  aii.l 

,.v.M  111.'  .'..ii-iau.'N  >.r  ilii-  -.MM1.I..I11,  Mi.li  :.-  II"  l"i';;'i- ■I'-i '  "''•' 

,lH.,.s,,.i-,.'ii,'.'..r  till'  ..l.i..'lix  '.l.-.rN.r..ttlM  I'n-.nl  .laN.  <  )n  tli,  ,'..ii- 
tran.  1  u-uKi  a-,  it  llial  .■.  .ii-i.l.  ral.l.  in.  I.  ■  .n-in  .  ..'.'niriii-  .  arlv  -.ar.'.iy 
IhI.'.mi:-  alii..n-  tin'  iiianif.-lali..ii-  ..f  a  u  .ll-ii.aiU.'.l  alia,  k  ..f  l>l.li..i.l 
i;.v.r   pni-uiiii:   a    iv.nlar   .'..ui-.  .       ll    i-,    in   U' ii.  nl.   aparl    ri-in    liual 

;,„.!  -iH.'ial    .■..i,.liti..n-.   ill-    1'-  '"I "    'I"    '^"'''■''    ''"■  1'^"""'   '"""''* 

,„„1.,,.   ,,i;-,'rv:i,i,.M    an.l    tli.     .^r.al.r    ll..- .ar.'  ^iv.'ii  lii.n.       rml.r  fav-.l- 

,,,,,.  ,„„.|i,i„„-    in    iirival.'    ,,i'a,li.'.'..r   ina  u.'IIh' In.'l.'.l    li..-|i.lal,  tli.' 

niiiil.T  an.l  ,„...!.  rnt.'h  ~<^'y  -■---.  i''  ■•''-iN.'l  .arly,  aiv  l.k.  K  ,..  I.r 
„„att.'M.l.'.lui.li    in..t....ri-iM.  or  at    ,n..-t    1..  .'Nlnl.i.    ,1    in    -lijit    .k-.n.'. 

M„n.     mark.'.!     .n,.t....ri-.n.    if    it    -k'Mk.p-    in    -|'i'<'    '■''    '^ '    •■a'''  ;.ii-l 

n.-tri.-t.'.l  .li.  t,  W  a  im.-t  ..niim.M-   ,nai.ir.-tati..n.       It  ,-  nniicativ,.  ..I   tli.' 

...xtivrn.-  -.'v.ritv  .,f  lli.>  .-ni-"  ..i'  tl,.'  .ii-.a-.'.  an.l    i-  .k')..  n.l.  nl  tar   l.-s 

.,„  ,lH.i-„..n-itv  ..ftlutyph..,.!  i..t.-tinal  l,'>i..n  than  M,...n  tlu'  int.  a-ily 

ofth. ni'iMl  inf.'.'.i..ii  ulii'li  i:iv.-  fi-.'  t..  |.an.ly-i-  ..t  tli.'  nn.-.nlar  lay.T 

„f  ,1,,  in,..-,in...  an.l  tli.'tvl.y  ...  M-a.,,,,,,  ,r,-,..„li.,n.       In  fufthrr  M.,,,H.rt 

of  thi-  vii'W.  it  inav  I..'  imnti' '1  '1'^"  -"V.'iv  int.-tinal    ,nanil.'Mati..ns 

..v.n  ruth.T  ,i,',-i-t.'nt  .liatTh.a.  I.>  n..  tn.an-  alway-  ,,n'.'...l.' .t  a.'.'...M- 
,,.„v  til.'  ,iH't.'..n-in:  an.l  al-,  .niiv.  i-.'ly.  ..Ii-tina..'  ,'i.nM  ,,iati..n  .-  i.v 
„„  ",„,an-  aluay-  a-...'ial.Ml  nilli  it.  It  ^.lurally  a,.,,.'ar-.  ..a  tli.' 
,',.nti-arv.  t..   1..'  a   >i^w\   "f  th.'   m.t.  ..ri-m. 

Til.,   in.livi.lnal   ,„,rti..n< -f  tli.-  int.'-tin,'  ar,'    inxiilv,..'  in  the -a—ns 

<li-t.'nt,..n  in  vari.-l  .l.-n-.      A-  ha-  1 n  in.'nti.-ni'.l.  tli,'  laf-.'  inl.-tin.', 

an.l  ..-,«-'iallv  th.'  tran^v.'i-.'  ...Ln.  i-.  a-  a  nil.'.  inv,,lv...l  in  .....st 
niark.Ml  .l.'-r-'.'  an.l  ni..-t  frr.|.icntlv.  Th.'  -mall  int.-tin..  i>  lik.'lv  t..  \n- 
,li-t..n<lc.l   K'S-  n.ark..ilv  in   .•..ini.afi-..ii    with    the  .'..l.Mi,   ..ffn    r,.n,ai'k- 


M  Mri'ii.MS     I  \/i 


I  1//7  /'    I  //"N  V 


liltl,.       I)r.iil(<l     iiiiti  Mii-m,    il     it     i 
.    I.H  all  il    H  illi    ini  |i  T-.  Ill  !■    ill    lli'i-''    |i 


l\..l\l       III!'      -IM.ll 


'2\: 


Nile  -lllH-     Ml 


III-     lllal     Mil,    M-     M     nil.' 


Ic-s 


Mil: 


i\     iiM'ilnii  IIS 


iiilillrMliiiii 


IIMIIlc   l\  ,    llli       II  'JIMll 


if'  llii'    |<;|iirii 


MM'I    nil'    ii|i|H  r    |i 

tl-MII-M   !•-<■     i"l"11, 


, nil. 11-    i.r    lllr    ill  lllll. 


iIm.'.'.! 


.r  lAJiiliiliiii;    M 


Irll     1  irrlllll-lM.li'l-     llli' 

IhiiiiiiimI   MrrMiiirriiii  III 


,|      11-     lllll-,    I11M\     I"' 


IhiumIIi    llir   mImI iliMl   umII-,   ill    IIk'    li'l'lii    "f 


-h  li-likr  liiii|i-  |i; 


—  IIILT    tl"MII-M  I 


-.In   mIii.vi-  Mini  Im  low   ill.'  iiiiiliili.il-. 


Ill  Mililiii'iii   111   till'  L'lii'  nil  "I'l 


in-  lllll   I'Mi'i  U    -i'\  I  I'l 


■mI    <li-liiil>- 


iiiii  -    lliMl    l:i\i- 

iVrrliiiikril     ill     ll 


Ci-r     111     ihr     nil  liiin-lll.    Mini 

iiMlii  III,  iiia-iiiiK 


11  ■      .ii|Mi|-l 


llial     air    llli     I ■!■  |-i':'i|lly 

ll    a-     lir    lllll-   IH'I     1        r  illl- 


aiiit    -iiULii'-l 


|||ii|-iill-ll     IiiimI     I  AMinillMliiiM. 


Ill  tl 


1-     rMll';;iil'N      liclull^ 


I  -licciaih'  rin- -<M  I 


lllll  1,1  lili.iiili-  Mini  iiilr-liiiMl   In 'iii.riliMi:v,  lli<'  ImII.t 


.luhiili  i-  liv  nil   iinaii-  mIwmv-  imlnaliil    ii  hik'' 


I  .\    till'  i'\  ai'iiMliiui  ol 


Iv   -I. 


iiiMi'i-.  r 


;tiiill   lit'    lllr    iiiiUrl.    M'Kulll      "r   ill!  II  — ll-<-.|>l  H  HI 


ilrll,   ll    I-  lllll'.  Ill 


•III-   i'ai'il\  ,  iiiii-l    mI-i 


ll 


imiijlit 


if.    ll 


ll  Ki- 


ll  in-lMin 


-  I   liM\  I'  iili-i  r\  I'll 


irki'il    nii'ti'iiii-ni  mii 


1    -\  liililiilll>  111    ilriis 


111   illl'irl    a-- 


i.iliiHi  uitli  lyi>liiii<l  |>i  rily|ililili-. 


ir.    lliri'i'tiii'i',    ni.iri 


ll    iint'iiri-iii    aiiiMMr-    ;:i  iiri'Mi 


M— iirlMlr'l     I 

iIhi'iIa    iiiip 


illrlliilllrll 


111  111'  utlii-r   -rr -   I'liii' 


itiiiii-,  ll    1-   liv  111!    nii'Miis 


illl     lIlMt     nil      il-     "" 


II    Mn'iiiinl    il    iiiMV  nut    r\rn    ininriiius 


rllirl-,    i-|M'rlM 


liv    liv    iliinini-liiiii:    iIk'   iM|i:ic'ily    uf    lli.'   tlmrax    an. 


Illli'l'lrrill'. 


with    tlif   r.'-|>ii'M 


liiiii.  Mlri'M.lv  >..   <rv:i\i 


I  ^  lllliilllMl   .ll-.'M-.' 


til.'  ri'-(iirMiiir\'  iiri.Mii 


tMlli'iill-  111'  nil    [i: 


ipMliiiii,  I-  VMnly  |ir.-.iit  un 


|\    tlii-.'Mt.'ii.'.l   !iy    llif 

Ali.l.miinMl  t.inlcni.'-s,  -|«iii- 

t  nn.l.r  iiriiiiiai'v  .•iiiiilitiiiii-.     In 


lll|ll|i'Mll'<i     CM-.' 


ill. Ills   .'.iiniilMiii 


tllMll    M    -I'll-.'   .1 

i-iii    lit'    niMi'k 


li'ii-inii  an  I    1> 


it'  Ml    m11,  "f  r-.Mrccly  III. If. 
—in.'.      Only  in  llii'  |iiT-.'n.'<'  of  incl.oi-- 


il-i'i',     even      It 


lallnll      ntli'll      III'     a 


lint    <it'    iiillMiiiniMtiii'y    iiMliin',    will 
1,1'    alli'iiili.l     witii     PMiii.        l''Mr     """•'•    .■"iinn.'ii    lliaii 


^('iiii'al  li'iiili'l'in  — 


Illl'  aliilnini'ii 


i-  li'inl.  rn.'--    in  tlif  iiirii 


It     lIlM.'   f.'— M, 


■h  i-  I'i'I'ii-alil.'    In  til.'  |>nr 


tinll    .it'     illll-IIIH 


|ir.'t'i  ralily  tlii'  -.'Ml   nt'  tlic 


llli'il'MllV'.'    prn.'.'— . 


11    -nllir    .'U'-.-   till-    tcll.l.'l'll.—     I-    !■<< 


n-lMllII\'    -.HIH'- 


wlial   liiLlli.'i'    liiwanl  tin'  il\(  r.  Mil 


1    tlii-  is  I 


>n--l 


lilv  .111.'  til  tlu'  ('.iniicnital 


ili-li.i'Mliiill     "i'     llli'    .•rllllll      lll>\VMr. 


I    (( 'iii--.'liiiiMiin),    will. 


ll    is   kiinwn    til 


iir   nut    ,it    mII    rar.'K 


Mi< 


I'Ml'     IIM-     I'Mn 


t'lillv  .tn.lii'.l    "ii'O   ."i-t-   . 


ty|iliiiiil  t'l'M'i-  Ml  till 


.Inliii-^  Hi.|ikiii-  n.i-|iital  with   n  t'l  rni.'.'   t. 


aiiil.iiii- 


iiiai  |iain  Mini  ti  nilii'in--. 
ai'i'  frrr  t'l'niii   pain  m'  tiinl. 


Ill'  t'nninl  lliMl  aliniil   tu  n-tit'lli- nf  tlw  |iati.'iits 


rn.'-s,  riili.  T    I." 


lllMII    111 


IH'-lit'.ll    llMVl'     tl'll 


III-- 


111'--  iillU  . 


I'Min    llllf     In     Sllinc   cnll.iilinll    ntlnl'  lllMIl 


till'   -ji.'.'iti.'   li.iu.'l- 


-inii-  \\a-  iii-.'-cnt   III  ali.iiit 


iii.),-t  rnn-laiitl\'  p 


t   14  per  .'.'111.  nf  til.'  .'M-i's.      It  iirri'.l  \mi1i 

M-i'-.       it  was 
ilK   -II. hi. 'II  ill 


i'Ikil;.     nr    |i.  i-fni'Mlimi    in    almnt    'i    yv   .'.n 


t.  .if 


I'C-CIlt    witll    lll'I'fnrMllnll,    Wll.'ll    It    WMS   11-111 


% 


mW 


•211 


ryrii'iiii  ii:vi:i;. 


ini'i'.      Ill   ahiiiit 


Hi 


|^HH|ifci( 


,,ii-ri,    -.vnv   in   cliani.'lrr.  mihI    piinAv-niMl    m   nvrurn 
twn-tifili-   nf  all    ca-r-    \Mtli   i)ain    iM   rniiM.   cuuM   \<v   W.nu'l. 

|„  ,.,,„„rrlinn«i.i>  tl,r,|I.MinM  :,.  t, ,  ^^  h.I  ilrl"  t  llrlV  i-  |.ain  a-ocialr.l 
xvi.h  :,n  i„tlanHa-,r,m--uira.-.'nv,ran  i„tlain.-.l  I '..v,,-  palrl,,  lie  ,|M.,t,.> 
,„  i,„..,vMln-  r.-r  in  uin.h  tli.  -.a,  rr  pain,  a-.riat,.l  will,  uiIht  -yn,,.- 
„„„-,  lr,l  to  M  ,lia^n<>-i~  nf  -nnir  a.ai.r  alMl.Hninal  r,.n,|.h.-at H.n,  an,i  an 
,.x,,l,,r;,ti.m    ua-   Wnnr    nn.lrr    l..,.:,!    mrain    anr-th.Ma.      -In-l    nn.lrr   thr 

,„,i,n   uImt,.   tl>r   |K,tirnl    IkhI   > plain,.,!   of  u-.vat.-t    pain    wa^  a    lai-v 

[•.v,v--  i,at,l,  uill.  ill,    -v,,.s,    n,n,i>    inllan,,.,!.      Witii   t\n-   UmuWuv^  ,>t 
,1,;.   inl,-lin,.   !„■   ina,l,.   n„  ,.„n, plaint    „f  l^ain.  I.nt    wru   a   -,.,,,1,.  „,n,.h 
„v,.r  Ihi-  intlanu.!  aiva  nia,!,'  inn.  ,t.v   ,,nl.       V,t    in  ..iIht  .■a>cs   pat,,  n,~ 
,„„1,.  n„  .„,npiaint  uh.r,  tl,,-  ...r„n>  M.rfa,-,-  ,,v,r  tl„.  nl.vrs  wa>  han.ll.-l. 
It  i^  ,,u,Mi,mal.l,.  wli,tli,T  <l,vp  iiKvrali.m  may  !.,•  a  .aiiM'  .,1    pani. 

Si,,.,,    tiu.    ti,n..    ,,f  d.^n,.!.    ,.lini,.ians   atla,-l,    n,.    little    iinp„|-tan,... 
,„    tl>..    ,.(.,.nnv,„.,.    ,.f    t:n.--lii.-    au,l   >i.la<hi„-.    wl,i,.h     it     i^    s,i,i    .-an 
;,l,n.,-t  .•,.„stantlv  l„.  i,„lnr,.,l    l.y  palpati,,,,  ,>f  tl,..  ,.,.,.al   n^rnn  ,„   ra^.- 
„,.    ,vpl,.,i,l     t;.v...-— ill.'     ,,nnjnu;ilr,n,Hl    „f     ti,..     \■^•r^^A^.        \-    t,-     tl... 
.„,,,nvi><...    ,.f   this    plM.n,mu.n,.n.   an,l    it>    Mfikin-   fiv.,i...n.>y    in    ..an.s 
.,r  ,vpl„.i,l   f..v..f,  thnv  ..a,>   1.,.  ....  .l.ml.t  :   la.t    I    wot.l.l   ,'all   alfnt,,,.. 

t„  tl...  Ih-.t  that  it  sl.,ml,l  ..,.t-a.  i^  oft..,,  th..  ....M,,,,.-!...  .•.m-,.l..,-...l  a.. 

i,„p„..,.„t  svmpt,,,,.  ,.f  th,.  ,li-aM..      1..  n.y  ..xp..ri,...,.,.  tl.,'  ph..n,.in....,.i. 

i.  .„  i„..,m>ta,.t  that   1  a...  ,„,t  in  th..  l.al.it  .,f  atta,.l.i.,-  ..np..ta.,t  .l.a- 
n.,.ti..  si>miti,.an....  .ith...- 1,.  it-  al.s..,..-..  „.•  it-  ,.,vs.........    Fn,...  th..  tl...„.vt,.. 

point  ,.t-  vi..w  alM.  this   i,.,.„n-.a,.,y  ,.„nl,l  s,.a,v,.ly  !„•  ..tlarw,-,.,  !,..•  tl... 
,|,.v..|<...!!!'.;it  a..<l  tl...  .li-t.-ihi.ti,m  ..f  th..  spi'-'iti..  typh,.i,l  mt..-tmal  l,.s.,,ns 

:,.VM.  'vafial.l..,  a-  has  1.......  p,,i„t,.,l  ,..,t  in  tl...  anat,,n.i,-  -...-tion,  that  th.. 

anat..n.i..  .•,.,..liti<,..s    in   th,.   h,NV,T   p„fti,m  ,.f  tl...   ih...,n   an.l   tl„.  ....,a.,„ 

,|,„    ,,,„h.r   th..  .U.x.hrni.a.I   ,.f  that  -y.,.pt.m,  phy.i-.ally  p.ws.hl..   a,-.^ 
1.1,1    fnltill..,!   with    ai.v  v..;^nilarily. 

Fi.iallv     it    inav   1...   n...,.ti,.i....l,  v^ith    ivf,..-,-..,'..   t.,    palj.ati,...    ,,t    tl..- 

,,„,„„„,„;, |,„   .,,,;.   -h,.,.l,l   1...   tak.   :    t„  av„i.l   ..„nr..-i.,,::-  ,.iiv,nn-..nluKl 
t..„.h.n,..ss  „f  tl...  al.,l„n,i„al  wall-   that    n.ay  !.,.  a-s,K.iat,..l  with  van..ns 
c.h-,!,.-..-  in  th..al.,l,>n.inal  ,nn-.l,-. -...'h  as  la,....-a.i„..-,  h,.,nat,,n.ata,  ...,.., 

wl,i..h  an.  U..,.w..  t,.,.,.,u,.   -„  lV..,,n,.ntly,  w.th  l,.,al    intla.nn.at,„y  p,'..-- 
,.„,..  in    ih,.  int..rnal    al„l,„ni..al  „.-ans.      !   hav,.  ,.hM.,.v,..l    th,.  ,.,.....nis- 

si,.ii   of  -n,-h   a..    ,■.•.■,,.■   in   a    i...inl"'r  "f  inMan,.-. 

The  Stools.  — It    i-  ,.n-t,,...ai-y  I„  -p'^ah  ,,f  a  ••  tvph,,i,l    -t,,.,!,"  a...l 
thi-  ,l..-i^nati„n    i-  ,„.pl-.y.-.l   t„  .l,-,..-ih.' a  p....n!ia.-,  an,l   th,  ,■,  Lav  ,1.,,^- 

n,.>ti..allv  in.p,„-ta.,t,  ,.|,a,-a,.t..,-i-ti,.  ,,f  th-  i..t.-linal  ,l.-,.ha,.n,.-.  I  n- 
,,„„,,„„l!v  ,h,.,li-,ha,-.,.-  «hi.h  a,..:  -p,.k,-..  -f  a-  typh,.i.i  -t.-l-  l-n-'-t 
a  iH.....lia>-    app-an........      Apa,-.,    h,.w,.v,...,   tn.m    tl...  .k..,.,a.-tfat„,..   -i 


SYMI-roMS   AM)   riiMI'l.lrMloXS. 


'Ji: 


liuiil-lKiiilli,  iicillicr  llirir  liliv-icul  iKir  llicir  riicinic  cciiililidii  |irc.-ciit- 


'M' 

;iti\  tliiiitr  -|"'' 


'lati'iii  uitli  a  iiiii 


tlu'  ^(i-r:i 


lira  t 


itic.      Tliiir  (iiai:iii-ti<'   value    roiWts  i'si»(ially   in    tlirir 
iilii  T  111"  "tlici- syiiipldiii-.      It    is  well    UiKiwii    that 
I  sluciis  arc  til'  1,  liuiiitl,  "1 


\  lllioll 


oclirc-vi'lliiw  ciiiiji- 


Tlicv    cxliihit    an    alkaline    reactinn,    and    they    |m,>m>s   at 


tune-,  alt 


h h  hv  no  means  alwav-,  a  iHcnliar  anini<inia( 


al  (xior.      I>i>!h 


)t'    the-e   <'li; 


iraeteristies   ai'e   at 


triJMited  l)V  I'arkes  and    l.chinann   to  tl 


ire-eni'e  ot' aninioninni  earlionati'  am 


I  a  ti.Ned  alkali.      It  i-  eharaeteri-tie 


ir  llie  -lu( 


a   u 


.1-,  when  iierinitted  to  stand,  tu  M|>arate  mxmi  nit'i  two  layei- 
ri-av,    tViahle,    ikieenlent,  <>i)ai|ne   one,  and   an   oscr 


iwer,   vellowi-n- 


Ivintr.   watery 
t    I 


tiirl 


id,   tiiinslneent   one 


that 


eontanis   i-eniai 


kalilv    littl 


(onlv  al)ont    1  |ier  eent.)  o 
alhninin    and    nnieii-.       It 


f  solid  matter  and  is   i)artienlarly  delieieiit 


IS    evil 


l.MitIv  thi>   detieienev   of    the    Hnid    in 


nniens  that  renders  it  incapable  ot    bcinj;  cmuU 


^(•(l   and  that  tiivors  the 


sepal 


atioii  of  the  typhoid  stools  into  layers 


.Micr<ps<- 
stnietures  ( 


ne    cxaniination    o 


t'    the   siHlimcnt     of    the   stool    disclose 


lerivcd  from   the  food,  more  or  less  altered  iiite.-tinal  epithe- 


linm,   detritus,   and    smaller   and    larj,^er    iiartielcs   of    sloiijrh,   and 


1  nn<l  third  \V( 


tlie  scciUK 

ot'  the  sloii<;h- 


pre-ent    in   small    number,   aiu 


'ks  even    larf^er 


hreds  derivtnl  from  cxluliatioii 


111  addition,  white  and  red  hlood-eorim-eles  are  always 
I    also   ma>ses   of    various    miero-or^in- 


So  1 


out:  aifo  ar 


the  vear  l.S:W,  Sehiinlcin  showed  that  in  aildi- 
ti(tn  to  all  these,  ((uantities  of  triple  phosphates  are  almost  constantly 
present.  AlthoU'rh  his  o])iiii<)ii  that  these  are  specific  constituents  of 
the    ty[)lioid    St' 


ool     has    not     heen    con 


ifirmed,    thev    are,    nevertheUv 


itl 


donhtedlv  more  common  in  association  with   ty|)hoiil  fever  than  with 
d,  theret'ore,   ar(>  not    without   dia<rnostic  siLriiifieanco. 


other  disease' 


oneernin<:    the 


presence  of  tyiihoid-liacilli    in  the  stools,  (U-tailed  state- 
ments havealreadv  been  made  in  the  ciia))ter  on  Etioloiry.    Their  hearing 


up  'II  iliairnosis  ca 


n  hi'  estimated  from  that  scciinn. 


It  must  he  emphasized  that  the  stools  just  descrihed  are  hy  no  nionns 
o  con.-tant  or  so  frccpicnt  as  tiic   inex]>erien 1  miiilit   helieve,  and  that 


I'licii    the   disease 


is   accomiianied   hv  an 


IV   diarrhea,    the   stools   are,    in 


jreiieral,  not   likely  to  he  exceedinjrly  iinincr.nis,  particularly  not    so  fre- 
(|Ueiit  as   in  the   majoritv  of  cases  of  acute  intestinal  diseases,  dysentery. 


catarrh,  and  allied  eondit 


ions 


F 


iree  to  six  thin  stools  in  tweiitv- 


toiir 
of  tv 


Uoiirs    ni.av  he   eon 


>i<lered  as   the  averaire   nuinher  in    the  diarrhea 


iver.      A    larjrer  niimher,  nj)  to  twelve,   i- 


less 


common 


Iv 


ohs(.rve<I,  and  then  onlv  for  a  short  time.  Ahnormal  fiei|iieiiey  of 
iiife-tinal  evacuations,  when  co'itinncd  for  ;i  considerahle  leiiLrlh  oi  time, 
jii-lities  a    fear   that    the   disease  will    pursue  a   severe   eours( — in    this 


f 


E-.  ■  ^^^^m^kmK--^S^ 


■2Hi  ivriinin  Fi:vi:i!. 

.uiiiurtidii  my  own  cxiMi-ifncr  i<  diliivly  in  iiccoid  witli  iliat  of 
\..<m'.  .Mll^(■lli^ull,  'l'r..ii",an,  and  -.llin--.  In  llic  al.-.^ncc  nf  Incal 
(li-ca-T  al  tlic  anil-,  -ndi  a-  lirniorrlnml-,  ti>-iiivs,  etc.  tlif  intotlnal 
.li>cliart;i>  >'f  lyplioid  i>atitiU>  aiv  alni<..-t  always  inialKiidiil  with 
jiain     ir  tciu-nm-. 

The  time  111'  the  tirst  :  .raranrc  and  the  (hiraticni  ot"  tlic  diarrhea 
exiiiliil  wi.le  variation-.  Nm  rarely  thin  >t.".l-  (pc-'iir  as  early  a-  the 
IH-odronial  Ma-e,  liefure  the  i.n-et  »i'  the  fevei.  'rii.y  are  ..t'teii  ineor- 
reetlv  attributed  to  riinple  int.>tinal  catarrh,  and  ceea-ionally  alx) 
to  the  e\ee-i'.  .■  and  protraeted  aeti.>n  of  laxative>.  whieli  ha.i  Keen 
adnlini^lered  i,,  overcome  exi-tin^r  ....nMipation.  At  thi-  time  the  di>- 
<-harp"-  d  >  not  ,-o  readily  form  layer.-,  and  al-..  are  oftui  dark  in  color, 
re-.mMini:  onlinary  diarrheal  -tiM,is.  therel.y  inctva-ini;-  the  ditlienlty  in 
diauMioM-.  This  apiKaranee  may  he  due  to  tiie  fact  that  the  alterations 
in  the  M.retion  of  l.iK',  parlienlarly  the  thinnin-:  and  the  lio:hter  color 
,if  the  -ecretion,  which  o<-ciir  >o  .•.,n>tantly  at  the  heijiht  of  the  di-ea-e, 
have  not  vet  l.cLnin.  Thi.  prodromal  diarrhea  may  di-aiiixar  with  tl.c 
l.ejri'  'itr  of  the  fever  or  after  the  tirst  few  day>  of  fev(  r,  not  to  re  ir 
thron^diont  the  entire  course  of  the  di.-ea-(>  ;  or  followed  for  a  feu  ys 
l,y  con-tipation,   le-   commonly  l.y  normal    evaenation>,  alter  which,  at 

\hr  end  of  the  tir-t  or  the  he-innin.L^  of  tile  s nd  week,  the  stool- a-ain 

heconu'  thin,  and  now  proent  the  characteristic  p..a-s,.np-like  api)ear- 
:,„.■<..  In  ome  ca—  stool-  of  this  .•haraeter  per-i.-t  thronudiont  the 
■,,,„;,,,  ,;,|,,ii,,  ,„,,i,„l,  rarely  l.eyond  this,  with  approximately  the  same 
„r  varvin-  frei|nencv.  In  other  instances  diarrhea  alternates  with  .•on- 
stipatii.n  or  with  normal  di-harp-,  <.r  it  .li>appears  pern.anently.  '1  he 
,.ati,-nt-  then  u-,nei~ally  remain  more  or  h'ss  .•.,n-lipate.l,  or,  what  is 
,„Meh   le-s  common,   the  int.-tinal   di.-.harjres  occur  n-nlarly. 

If  an  .'xact  -tafment  is  .lesi.v.1  as  to  tiie  fr...pi.ncy  with  which  diar- 

rh..a  ur-  in  .'Mscs   of   tvphoi.l   fever,   it   may    he    said   that  diarrhea 

thron.diont  the  whole  or  the  lar-.T  part  of  the  fehrile  p..no,i  ol  the  .lis- 
,,,.,  U  likelv  to  occur  in  narcclv  one-third  of  all  the  cax'S  while  m 
,,1„„„  ,„  ,,|n:,llv  la,-e  nnmher  diarrhea  occnr-  hut  tran-iently  or  m 
alternation  with' -olid  dl-.ha.-..^.  Of  o«o-  .•^•^-■>  tluit  I  li^ve  exam- 
ined with  iv..,rd  .o  thi-  ,>oint,  iL'sfi  i„.lonL.'.l  to  the  first,  and  1 :!..!) 
,„  the  .-.-•ond  ,.ate.orv.  whih-  II  S7  wcv  thron.hont    frc  from  diarrhea 

The-e  ca^e.  of  tvphoid  fver  "witholit  Ivphoid  -tool-"  .h-.TVC  e-pecal 
con-id,ration  from  the  dia,:no-tic  -tandpoinl.  The  novice  i-  iar  too 
ivHlilv  di-po-ed  under  Mich  condition-  to  donht  the  exi-tence  .,1  the 
di-e-,-'e  The  experien.vd  phv-ician.  however,  may  ->  still  further,  an.l 
..Kiintain   that  of  this   larp.  nnmher  of  .■asc.  whhonl   thin   <tools   more 


SYMl'ToMS  AM)    (  iiMl'l.l<ATI<>\s: 


217 


tlum    liair  Mctu^illy   miIT,  r   fn.in  .■nii-ii|,MtioM,  riv.|n.'nllv  iliiou^^'iioiit    tlie 
x\l„,K.   com-r   of  the   di-ra-v,  Ir-    niuouly    t;.r    a    -ImiH    time. 

Thr  foll..winir  fiL'urcs  will  ilh.sirato  tlK■^.•  ivlati..iis  .norc  a.vuratcly  ;  and 
i„  ,|,i.  ,.„,mu'H;.>u  il  MK.vl.i'  Munlioiifa  tliat  llu'  1a-ii-»"  slalislic.-.  «liirl. 
i„,h„l..  all  thu  .•as..s  ol,s."rvnl  at  llie'  nu.li.'al  rlnii.'  .lunnL:  t,.irt,TM  v.ar., 
m..ro  nearly  api.n,xi.natc  the  ireneral  prevaU.,.  ron.lu.nns  that,  the  llain- 
hurr  statisfirs,  whi.'h  ecver  a  .in-le  epi.leiuu'.  l.:ke  M>a„v  other  ehnu^al 
nianif.-talicMS  -f  tvphoi.l  fever,  the  variat'ums  ii.  the  inleM.nal  -liM-har-es 
al...evinhU  tint  i,M"onsi,leralile  loeal  aii.l  temporal  diliereiKv..  Nevertlu- 
les.  a  comparison  of  these  titrures  .lis.-lo.es  on  the  whole  .■onM.lerah  e  agree- 
ment Of  "'40  eases  .Inrinir  the  Hanihnrf:  ephlenne  <.t  ISH,  that  were 
inve<li<'ate,l  as  to  the  state  of  the  s.ools.  .liarrhea  was  present  throu-hoi.t  in 
,S()')_:;(;  1  ,kt  eent.  :  the  stools  were  normal  thron-hout  ni  1  lb— .).-  |.er 
c..nt  •  ...instipation  was  present  throughout  \n  7>(u--2r,.:]  i,.'V  r^uU  :  unnua\ 
stools  alternate,!  wth  eonstipat.on  in  .V.'--.:i  per  eent.  ;  transitory  , harrhea 
nltor,.ate.l  with  normal  stools  in  20-.'-!»  per  eent.  ;  tranntory  .harrhea 
alternate.1  with  constipation  in  424-l.\!»  per  cent.  ;  .harrhea  alternated 
with  constiiialion   ami   normal  stools  in    :?'.•— l.s   l';'"-  "ent. 

Of  1S7,H  ca.ses  observed  at  the  Lei psic  nie< Ileal  .■linic  hetwecn  the  vear, 
ISSO  and  1H!I:!.  which  were  investigated  from  the  same  point  ot  view 
there  was  found  .liarrhoa  thron^d.out  in  4.S0 -•.':.. (i  per  cent.  ;  j.ormal  Mools 
thron-hont  in  .H'!— 4.4  p«T  cent.  ;  constipation  throughout  in  •'';|-l''->  I"'" 
eent  •  normal  sto,.ls  in  alternation  with  constipation  m  (.2—0.0  pei;  -•eiit.  , 
diarrhea  in  alternation  with  normal  stcmls  in  144-7.7  i)er  cent.  ;  diarrhea 
in  alternatiou  with  constiiiatiou  in  oM—-2'.K->  per  cent. 

Bloody  Stools.— The  hemorrliajrie  d!-eliar<,'es  \vhi<'h  arc  lierc 
cs|HH'iallv  referred  to  are  those  that  take  plae.'  fnun  poninns  ,,f  intc^stino 
the  seat' of  ll'C  specific  lesions,  and  therefore  -tand  in  <liroct  relation 
with  the  tvi.hoi.l  process.  Care  siioiild  he  taken  to  avoid  confusinij; 
these  with  "the  acci.lental  admi.Kturos  (d'  hlood  fion,  the  lower  portions 
of  the  rectum  or  the  anal  re-ion,  due  to  hemorrhoids,  fissures,  an.l  the 
like,  wliicli  not  rarely  f,rreatly  agitate  the  layman   and  may  occasionally 

lead'  the  physician  into  error.      I'n.hM-  these nditi.ms  the  hlood  <rener- 

allv  presents  a  fresh  apiK'arance  or  is  foim.l  in  e(Mfriilated  masses  or 
admixed  with  mucus;  it  is  deposit.'.!  ui.on  or  lies  iK'sido  the  lecal 
matter,  and   is  never  intimately  adntixe.l   with  it. 

True  intestinal  heniorfhaire  is  one  of  the  most  impoitant  events  hi 
the  ••ntiiv  ••.mrse  of  an  atta.'k  of  typh.id  fcvr.  Th..  amount  vari.'s 
hetw...n  sliiiht  a.lmixture  of  'h-o.!,  ,.ffn  di-tinoui-hahlc  with  ditlicnltv, 
ev..n   on    niien.scopie  examination,  an.l  the  mo-^t  ]>rofi|sc   hemorrha-es 

the  1,1 1  heiuiT  di~charir.'.!  from  the  how.l  in  liter-amounts  am!  rai.idlv 

.•auHug  .l.^ath  l.v  lo~s  of  hl.H.d.  In  a.rordan.v  with  the  amount  ami 
the  -onrce  of  (he-  hlo,«!,  an.l  ti,.'  tim.'  that  .'lapses  l,,.twccu  th.'  exti,  i- 
siliou  an.l  the  di-.'liar-,-  with  th.'  -tool.  ih..  latt.-r  will  pr.'scnt  a  varial.le 

1  I,iai,a.  iJ'S-  .   I.'i|'-i.'-  i^'-''''-  h    "'■'-• 


'   ! 


U 


M 


^Ilii 


•2lH 


ll! 


l^j  a 


Tyrii"ii>  Fi:vi:i:. 


-li-lit    a<lllii\tlin     i>t'   hlnixl,  tlic    stmil    i-; 


;l|i|M'ar.-inci  .        It'   llicn-    \>r    I'Hl 

likilv  U>  l.f  vrllMwi-li-rcd  HI-  KiMwni-li-iv-l  in  n'hn:      1 1' a  ((.iiipaniliv.lv 

la|.M-,".  aiiKHiiU  ..r|,l 1  i-  uia<lnall_v  r\trava-ali<l   and    i-    not    cxiM-llrd  at 

oiirr.  it  will  a|i|Mar  a^  a  li(|nid,  fn>ni  dark  l.mwn  to  fcd.li-li  Mark  in 
,.,,l,,r,  or  even  a-  an  alnio-t  \\li,'lly  lilack.  vi-.id,  tar-likr  ina-.  oficu 
uilli  a  -iceiii^li  liiiLT.      If  tiif  li(inoiTiia-v  tak<-  place  rapidly  iVom  on" 

or  -i'\i'Vu\  lai-L'..  vr>-il-.  and    if  the  liloo.l  i-  - i  .xprllcd  a-  a  iv-nll  ot' 

acrrln-atcd  |Mri-talli.'  iiiovenit'iit-,  the  >to,.i-  ar(|iiirc  I'alii'T  the  character 

of  -iniplc  loaonlatid   Mood,  namely,  ivddi-h-i)laek   or  Mood-red,  L^encr- 

allycoaLMilatcd.  nia>>e-,or  not  i-aivly  dark  ilnni|»of  i.loi.d  in  a  rapiid  -tool. 

The  n^nal  linic  for  the  ocenrrcnee   of  tlii-  dreaded   accident    i-   often 

.-tatcil   to  he   later  than  my  experience  indicates.      Altlioiitrli  h«'al,  tcm- 

p<iral.and  individnal  inllnciiccs  may  he  opTativc   in    tlii-   eoi'nccti.ai,  I 

helieve  the  .-tateinent   i-  ju^titied  that  tnlly  ;'.<)  per  cent,  of  all  intc-tinal 

hein..rrhaj:e-  o<'cnr  within  the  tir.-t  two  week-  of  the  disease,  and  then, 

natnrallv,  the  more  freipientiy,  the   more   nearly  the  close  of  the  second 

w,-ek    is"  approa.hid.      J   have  cv.n    noted    p.riodM  Hinnl.nrj;  eiud.mic 

of    1SS7)    in    which    half   of   all    the    instances    of    li.inorrha>re    I  H.H 

per  cent.)  were  ol)-ervt><l  dnrinj:  the  iirst  two  weeks  of  the  disease,  while 

•24. 4  per  cent,  were  smi  in  the  tliird,  and  i:'..4  .        e,.„t.  in   the  fourth 

week.      Mv  experienees  at    Lciiisic  confirm   the;  cnieuts,  and  they 

are  ])erhaps  even  more  striking.' 

The  average  eoiKlilions  inav  he  iialicatea  liv  the  follow  iiij:  figures  :  In  148 
cases  of  intestinal  h.-iuorrlu.-e  :  llaml.iir-,  l.s.s(l-  l^M  :  the  hleedni- o.riu-red 
from  the  -ixth  to  the  iiiiuli  dav  in  ll'.  from  the  tenth  to  the  tuellth  .lay  m 
'>:;  from  the  thirteenth  to  the  fifteenth  day  in  'J:'..  from  the  .sixteenth  to  the 
ei-hteenth  dav  in  :?1,  from  the  nineteenth  to  the  iwc  iity-first  day  m  l.,lrom 
the  twentv-se.V,n.l  to  the  t«ci.tv4o.irth  day  in  '.•.  from  the  tNventy-filth  to  ti.e 
twentv-..venth  <lav  in  11,  from  the  luenty-cighlh  to  the  tlnrt.eth  dav  m  10, 
from  the  thirtv-first  to  the  ihirty-tifini  day  in  :'..  from  the  thirty-lourth  to  the 
thirtv-sixth  day  in  4.  after  the  thirly-sixih  day  m  •». 

As  there  can  he  no  .pie-tion  of  cNtcnHve  exfoliation  of  sloiiirlis  and 
the  opcidnir  of  lar-c  ve-els  l.efore  the  -nd  of  the  sccoml  wcc4<,  these 
earlv  hemorrhages  nui^t  have  some  other  -onrce.  As  a  matter  of  fact, 
they  take  place,  as  anatomic  inve-ti^^ation  -how-,  from  the  so.  ,  sjiongy, 
cx.MM.linJv  hvp..remic  and  fiiahlc  ti-ne  of  I'cyer's  patche-.  uhich  i.s 
discolor.'<rdark  re.l  to  Mack,  and  which  may  nndergo  this  ,-erioils 
alteration  as  earlv  a-  the  l.ctrinninir  or  tla-  nd.hlle  of  the  second  werk, 
"in  -om.i'  in-tan. 'c^  .'v.-n  .arli.r.  Fr.,m  this  -..nr.v.  if  tuMn.nm-  I'.y.f's 
pat.'h.-  ar.    in^U.-.l,  th.    hem..iThap'  mav  h-  a-  .M.pi.ms  as  fn.m  er.,de.l 

lar'_'.'  V.--.  Is. 

>  .'Sw  li.T-,  /.".-.  nf..  |.    18. 


^_J:Cv:*:;v;!vi/;,., 


-JT  • 


•i.i;' 


SVMIToM^i  .l.V/'   cnMI'l.irArinSS. 


•Jl!» 


Alter  thf  «nil  of  tlic  -ccond  ;iii(l  tlic  l).<riniiiiis  of  tlic  tliinl  week  llic 
IumiimitIki-.s  Miv  naturally  nc  l"ii^'.i-  dw  U>  tlic-c  all.rati..n>,  i.ui  to 
..xlMiatiuii  of  tlu'  >loii>:lis  from  tlic  alfrrtiKl  I'.'Vcr's  patcho  and  s..litaiy 
folli.lo.      DciHiKiiMi:  upon   tlu>  x'at   of  tlif   infiltration  au.l   the  <l.j.ili 

;„tain.-l  l.v  il,  oi '•  """v   smaller  or  lar;,r,.r  vessels  aiv   simullaneoiiMy 

,.,o,l,..l.      InaMiiii.li   a-   the   pro.-ess  of  inliltratioti  and   uleeration  of  the 
Ivmphati.'   inle-tinal   apparatu— as  unatoinic  ol.-eivation   shows— iloes 
not    tak.'   plae..   at   a   shi-h' stroke,  hut   rath.T   slouiy,  in   .ta-e  ,  >o  aU, 
i.  th-  peri.Hl  ill  uhieh  heniorrl.i-e  is  .l.p.ii.l.'nt  upon  it  often  .piitc  Ion-. 
Kven   at    the   time   when   all    th.>   uhvrs   may    he   thoiijrht    to    l>o    elean, 
,,r    in     jrreatly    n^lneed     individuals    many    w.vks    after    this     period, 
hemorrha^rcs,  ^Minetimes   .,f  fata!    de>rre<',  inav    yet   (.(•••ur.      These    result 
fiuiu  inii)erfeetly  thromhosed   vessel-    ill    the    floor  of  uhvrs,  often   also, 
ev.n  when  the  intestinal   lesions    in    jreneral    appear   to    he    heah^l,  from 
i-..lated   shifT^di-h    uleers,  situate.1    i.oth    in    the   small  intestine  and   also 
nlatively  (|uile  frecpienily  in  th.'  larjre  inte-tine.      This  iutfrftinal  liemor- 
ih.iire  mav  he  ol)served  to  oe<'nr  as  late  as   between   the  thirtieth  and 
the   fortieth  day  of  the  disease,  ami  oven   still   later;    I   have  ohserveil 
it   on   the   tifty-seeoiid,   fifty-tifth,  and   fifty -ei^dith   days,    resi)eetively. 

Hemorrhajrcs  appear  to  he  imieh  less  common  diirinj;  rela])ses  than 
diirin;::  i)rimary  atta<'ks  of  tlie  disease.  Of  1  ."):5  cases  of  hemorrhafz-e 
that  I  have  analvzed,  this  eomplieation  oceiirrcKl  in  only  4  durinf? 
relapses. 

The  nnniher  of  bloody  stools  that  occur  in  the  individual  case  is,  as 
a  rule,  overestimatetl,  as  it  is  usually  stilted  fndn  memory.  In  ireneral, 
there  iiiav  Iw  from  1  to,  at  most,  t,  which  tisually  are  expelled  in  suc- 
cession at  relatively  short  int-Tvals.  Much  more  rarely  I  have  observed 
a  larirer  luimber  of  l)loo<ly  stools,  from  ti  to  10,  and  only  in  isolated 
instances  more — up  to  20.  In  the  latter  cases  conditions  of  the  so- 
called   hemorrhaijie  diathesis  are  probably   irenerally   present. 

( )f  -''iii  eases  of  intestinal  heinorrhiiire  ohserveil  at  I^>i|)fiir  and  ITamhurfr 
that  I  :.  ilv/id,  fnini  1  to  4  hl.Midy  stools  occurred  in  22'),  and  a  larirer 
niiiiilier  iiidiilv  :>1  :  Imt  of  this  latter  nund)ei  the  oases  with  1  and  2  stools 
|>re|«)ii(ierateil.  There  occurred  1  hliioily  stool  in  7H  cases.  2  Itloody  stools 
ill  TiT  cases,  :>  liloody  stools  ill  4.")  ca.-ies.  and  4  bloody  stools  in  4.')  <'ases. 

With  roL'ard  to  ai:r  and  sex,  the  mature  period  of  lift'  i>  di-linetly  tliat 
at  \vhi<li  int.  stinal  heniorrhaufe  iuos|  frei(nently  occurs.  It  is  much  less 
common  in  children,  and  this  >taleiiieiit,  a<rn'eiii;r  "''tl>  that  of  Henoch 
and  iJilliet  and  ilarthez,  as  apiiu-t  o|)po^ite  statements  by  a  number 
of  other  ob~ervers,  I  can  confirm  positively  U|«m  the  ba-is  of  a  larire 
number  of  cases.      While   in    ..<lults  I    have  at   certain   times  ol)>ervi>«l 


i 


I' 


^mj_  j.-a^V""^-yi?^^^?^-|HP^!^J^^:^-:":y^W  r 


•_'-J(  > 


TV  rill  nil  ii:vi:n. 


Turmtuss^ 


ii,irMiii;il  li.MK.rrliajrc  in  ms  lii-li  a.  10  Mii.l  .'vni  1  1  jxr  .vhl.  ul'  all 
IMticM'.^  I  have  ii.ilc<l  it  ill  s.'aiv(ly  1  |h  r  .■..it.  in  .liiMnn.  l)..nl.t- 
l.ss   tlii-   cin'timstan..'   i>   n  la.cl    tu    tlic    ii-nally    IrsMf   fxt.nt    :m.l   in- 

t.n-ilv   of   tlu'    tvplioi.l     iiililti-atinn    ..f    tlif   inl.-tin.-    in   .■liiMti 1.      I 

liav.'lHvn  nnalilc  to  not.' any  mat.  rial  .litr.T.n.v  l..i\Mvn  tli.'  t\\.i  m'Ms 
with  ivf.Ttn.r  to  tlio  fiv.]!!.  n.y  of  iiciiiofiliajr.'.  Willi  n.L'anl.  Im.u.v.t, 
to  til.'  MV.iity  aii.l  til.' .lanpr..f  tlii^  Mniptoin,  in.n  a|.i..'ar  .li-tiiutly 
,,,   .||-,   ..|ii   till'  t;ravi'r  coiulitioii. 

In  ailult.-.  ill  iiiv  e.\|ierifn.e,  tlif  fn^iufncv  of  lii'iiiorrliaL'.'  is  .|niti'  liniit.'.l 
up  to  ill.'  tliirti.tli'  v.arof  life,  aMioii-li   frreaUT  than   in   (■liiMr.'ii.      Aitfi- 

ihf  ihirli.tli  voar  tiuT.'  is  a  noteuorthv  increase,      'riic  nuixin i  is  r.a.hf. 

hi'tu.-eii  tlK'Vurtv-liflli  ami  the  tiftiilh  year.  althonL'h  later  lif.- also  is  Ml  1 
exi«»e.l  to  ri>k.  "  I)i:riiiir  some  e|.i.leniies.  it  is  true,  exct'litions  to  thi>  rule 
appear  t.>  .x'.'iir.  ■flius.'iii  Haiuhuri;-  in  \xx'i  voiiiiL'  persons  suHere.l  tr.tni 
intestinal  heniorrha-e  with  relativ.'  fre.iueiiey,  as  the  folloNvmj:  ti-nres 
slum:  Fr.im  tilteeii  t..  twenty  v.'ars,  'JT.T  per  .'eiit.  ;  twenty-one  to  t\U'iity- 
tive  years.  ■-'•').:!  i>er  .eiit.  ;  Iwentv->ix  to  lliirty  years.  -Jl.T  per  ei  nt.  ;  thirty- 
.aie  "to  thirtv-tive  v.ars.  10.^  Jier  eent.  :  thirty-six  to  f..rly  years,  4..H  per 
eeiit.  :  tortv-oiie  to"  tiirtv-tive  years,  5,-t  per  eent.  ;  forty-six  to  hfty  years, 
l.-J  per  .■eiit.;   lifty-oiie"  to  tifty-tive   years  \:1   per   cent.;   tifty-six    to  sixty 

years.  X.'l  per  cent.  ,,.,,■  i-  • 

■  Oil  the  ..ther  haii.l,  the  year  \><x^\  .xhihite.l  the  iollowmj;  .■.ai.litions : 
Fn.m  tifl.'.ii  to  twenty  yi'ars.":i.4  jier  .■.nt.  :  tw.nty-..ne  t.>  twenty-fiye  years. 
4  !.  per  .'.nt,  ;  twenty-six  to  thirty  years,  4.!l  per  .cut.  ;  thirty-one  to  tliirty- 
fi'ye  years  7  1  i.er  ".'.•nt.  ;  thirty-MX  to  forty  y.ars.  14  per  .•eiit.  ;  torty-one 
to  forly-iiy.'  years,  7,7  iK'r  cent.  :  forty-six  to  fifty  y.'ars,  •_'  (K^r  eent. 

The  fn'.iii.'n.'y  .'f  h.'in..iTha're  in  r.lation  to  th.'  niinib.'r  ..f  .'ases  is 
varionslv  stat.Kl  l.y  .iim'f.nt  olwryers,  Xatui-.iUy,  it  inak.'S  a  niatifial 
dim.rei,.'..  wh.'th.'f'on.'  c.n^i.ier.  .miy  lar-.'  ami  .'..pLais  iu-niorrha-.s  ,,r 
inelii.h's  .y.'n  tii.'  -.li-ht.st  a-lniixture  of  hh"..!.  Tiii>  .■iivnnistam'e  may 
exjilain  s...ne  extrem.ly  !..^y  as  w.ll  as  so.iu'  extrem.ly  lii-h  estimates. 
Ahove  ail,  it  slionl.l  !>.■  .ini.lia-i/e.l  that  th.'  fi'.'<|n.'n<y  ..f  Inniorrha^re 
vari.'^  -natly  in  .litf.'ivnt  y\m-v<  ami  at  .litV.'r.'nt  tiin.s.  It.  my  exp.- 
rieiie.'.  H'  tii.Ve  ea-.-  -li..\yintr  only  :«  t'""'''  :>'"''  ""'  in.ln.l-'.l,  aii.l  the 
„„.an  of  many  y.ar^'  .xp.ri.n.-.'  in  .litr.r.nt  plai-s  is  taU.ii,  tiie  ay.'fage 
<n.,pieii.'y  ..f  int.'-tinal  hi'inorrliap'  i-  fmiii    I  to  C,  per  .'I'Ht. 

lu  l..'ipsir  anuMiL'  Iti'-^tl  .'ases  of  |ypli..i.l  fey.'r  ...•.'lirrin-  in  the  course  of 
thirte.'n  y.ai-  I  iiot.'.l  Id:!— C.:'.  p.'r  .'.'.it.— in  whi.'li  lu'inorrhaire  o.<'urre.l 
\Mion"  the  much  lar'vr  nunilMT  nf.'aMS  at  Haiuhui-,  lu'inorrha-.'  o.curre.t 
in  l.ti  p..,-  cent,  in  l-ssC,  ami  in  :'..<  per  .'.'iit.  in  1.^.^7.  '1  hese  ii.-ures  a-ree 
wilh  tl'n.e  of  (iri,ssin-.r,  who.  anion-  (10(1  ca>,-s  of  |yph..i,l  (eyer,  olw'ry.'.i 
l„.„„„-rha-..  in  o.:!  I'.'r  .'.'ut.  lloinoile  .olheteil  the  enonn..ns  niinil.er  of 
KMHM)  ca.-esof  typhoi.l  f.'yer  from  yariou-  .-oiirces  i  inclmlm;:'.  anioiii:  .others, 
L.)uis.  I?arth.  i;ai:aine.  De  ( '.  rouyiUe.  ( iriessmirer.  Li.'hernu'ist.'r.  (  .ol.Kiam- 
nier  .iesM'ii.  CliyoMck  i.  aii.l  foun<l  intestinal  hemorrhage  to  hay.'  oc.'urr.'.l  in 
4  Cm  percent.  Lieh.'ruuisler  phi.'.'S  the  tiirnre  r.'latiy.'ly  hi-h,  namely. 
7  :j  ner  cent.     The  stale.iient   that   has  found  its  way  into  many  hooks,  that 


oMrniMs   \\i>  c'lMi'iK  \ri<)ss. 


221 


M 


iirclM>"M 


li;i.l 


mtoliiiMl    111 


iiiorrlKiL'i'   m 


1  t').(i  |i(r  I't'iit.  Ill'  lasi :-. 


iinoii  ;i  iniM'iiiii'i 


Miiriliisoii 

|iiT  rilil. 
tlir  yran 
cMsts  in   the 


iltsfi-scil   14    iiiniili: 


nlioii         Till'   tiuniro  <u<  imi    nl.-i    |..  (..ill.  iil.~  al    a 

I  .        ,  ,  ..!..■      1 1 1  1 


■  I  ilialli~    :l.-   :i    |-i>ult   nl    In  aml'i 


ha-i-      lii.fi 


Tlic   ti'.'iiri'.-   L'iM'ii    in   llii'    ic] 


s    l^.'p.")    1> 


.11.    iiaiiii'lv. 


,f   ihl'    Wii.icii    llu^liil^tl    I'T 
kal.U   l.iu.      (If  m;'.i 


■111.,  air   rciiiar 


Ic.liiis  Honkiii^    Hn.  |.ital.  Iniiiorrha,-.'  >«;un-< 


I      ill    ti     IhT    Cllll. 


Amniiu'   llir  iM-itmii'  caii-r 


llir  iiili'-liiial    liciiiiin     ip',  ' 


Irlclir  iri-Mi', 


n-Ilr--n(-- 
iiia\   I"'   nil 


HI    till'    y 


irl  "I    liir 


lalinit,  r-|ii'i'i:il 


iiii:   up  I ail 


iiliiiiinl   a~    till'  iii"-l    livi|ii(iii. 


'I'lic-f   tiictiiiv  ai 


ilaiii  llir   la'-'    'lial,  m 


inaiiil 


—I-   ii-cll    liy    iiui'\i>< 


liatli-  ma 


lit'  tvilniiil  livi  T  willi  '■ 

i.riliaL'i'   tlial    lia-   alrcnly    urciirrfi 

1,1, ■    of  dirrcliv  rxriliui;-    tlir    lli'llliin-|l 


■\|H  riciicf,  aiiiliulalun   Iy|p|initl   trciiuiilly 
■In!    iiiti-tiiial    liciiiniilia^'i-.      'I'lu'   trcaliiu'iit 
lcii>il'v  iiitr.-tilial    liilii- 
|_       It    i^,   liiiuivrr,    |)inlialily  iiicapa- 

I  ill  wli 


|),l^-ltll\■    HI 


1     -till    prarll-nl     tVri|llillt 


iili-ri'sr  111 
lialliiiii;'    It 


iiiiirrliauc  "I'li  !;'''■■' 


|)iilili;;  the  |)ii'lo(|  in  wlmll 
1  <•,,!. 1  hatliiiitr  1  <li'l  iii't,  ""  ill"  ^*ll"l'■, 
t,T   l'r,c|iirii(y  than  >iiH'<'  1  \:a\v  cinpluvcd 


in-iiii(iit 


Iv    1,.-,   cnM,   ami    will 


I   nil  iff   ri'i;an 


I   to   till'   iiiiii 


Altlmiiuli    l-ii'liiTim  i-l'i' 
hrfolr    tllf    intniililrti  'II 


Vlillial  ra-r. 
ci'iit.    of  i'a~ 


introduction    iii   mily  'p.-    J" 
liim.  due  inainlv  to  tlir  u-i' 


I-     I'Cllt..      t 


ili-crvi'd    iu'intirrliai:!'  in  •"<.  I  p^r 
of  livdriitln'1'apy,   ami   afin-   its 
he    rciliii'tiiiii    Ixiiit:,  arrordiu;^   to 


,f  livdnithci-apy,   I  would   point   out  tl 


lat  111 


H 


iiiiliiirtr,  wit 


h   alino-t    piiri'ly    ('X])('<-tant    trcaiin 


inuiit.   at   anv    rate  wit! 


onlv  till'    iiifn'i|U('iit    iiiiployimnt  ol    Datli-, 
Imt  ■\.>^  jii'i'  I'l'Ut.  ot'  ra 


f  l)atli-,  we   oliMTVcd   luiuoniiaui'   in 


Wit 


h   iv-ard  to  till'  .'liui.'al    manil".->tation,  of  intcMinal  licinorrlia 


it  niav  I..'  -tal.'d  that  it-^  on^(•t  i<  rarely  announced  in  :"!^ance  in  any 
special  inaiimr.  On  the  c.intfary,  the  liemonliaire  often  n.'cnrs—"  like 
a  11  i^h  of  li-htiiin-  ill  a  .'h'ar  ^ky  "—at  a  time  wli.n  the  i.atieiit  feels 
eiilireiv  well,  and  the  friend-  an-  luo-t  lioixfiil.  Ahduiiiiiial  pain  rarely 
precedes  the  lieinoriha-e.  Only  now  and  at;aiii  iiave  I  ol.sevved  severe 
colic  and  iHTi-taltie  unrest  of  ttie  int<'-tin.'s  fur  from  one  to  several  days 
iH'fore  the  onset  of  the  hcinorrha^n',  Imt  I  am  inclined  to  .ittrihiite  these 
-yinptoin-  ratlier  to  the  ultiliu/e  (e'.citinjr)  cause  of  tiie  iieiiiorrha^'e 
than   to   the   latter   itseit'. 

MeCrac.'  in  his  analysis  of  ."lOO  cases  of  tyjihoM  fever  with  reference 
to  ahdoininal  pain,  found  that  pain  was  present  in  14  of  the  .".(i  cases 
in  w  hich  liciuorrhair<'  oe('iirre<l.  It-  importance  is  esni-ially  in  reference 
to  the  ditVei'cntial  dia-nosis  hctweeii  tiiis  complication  and  perfomtion 
of  the  hoxvcl.  The  frcipiency  with  which  hoth  eomplii'atioiis  occur 
-imnltaneoii-ly  may  he  seen  from  the  fact  that  of  ;i(i  eases  of  perfonition 
ill   the  Johns   Ilopkin.-   Hospital,  f,  were  aeconi))anied  hy  hcniorrha^'c. 

'  Lo<-.  cit. 


:m 


■j-j-j  / )  rii<iii>  1 1  III:. 

In    :i    (Idiilitliil    i-A-i,    Willi     I'Miii.    till-     lildoi!-.A:iiiiin:ili (lay    -Ik.w     a 

iii;iik(il    i|iM|,  ill    III -I"liiii   ■iml    niiiiil"  r  ><\'  ivil  (■..i-|iii-c-|i-    Inli.r.-  any 

1,1 1    :i|,|i,  ai-  r\ti  riiallv.       Tliayii'    lia-    I'miinl    tlial    Ihiih  .nliai:c    tV 

lllr    Im.wi  1-    llia\    lir    Inlli'Wiil    li\    all    illrlrl-r    ill    lllr   IllUnl"  I'   nt     Irllkncy  li  -. 

r.arliiiii;    it-    iiiaxiiiiiiiii    iii-iili     i.l'  iwi  iils -tinir    lioin-.       in    -..nn     ra-i -. 

li,.\\,\rr,  till-    lir niia-r    lia-    li"    .llivl    ..n    llir    iiiiiiiImi     .i|'    Iciikocylr- 

in    tlir    |irri|iliiial    i  irmlalii'ii. 

In  ra-i-  ill  \\liirli  lllr  |ialii  III-  air  in'I  alivauy  i^rtally  ivdiin  il  in  cmii-c- 
nuili.r  i.|"  aiitiridr.ii  (ii-ca -r  i  .r  i  .1'  I  lir  -|  icria  I  -lAriilN  ami  l^nt:  till  rat  inn  nf 
tlir  allark  m1' t\  |ili.,ii|  li  \  .r, -li-lit  uriA.n  nKnii'i-atciy  -i  \  rif  jirinnnlia-i - 
ill   -niall    iiiiiiiImt  caii-c   im  material  altifatioii    in  the  -. m  ral    ciiiiilinnii. 


l>n.t'i!-c  liriiiMiTlia-r.  linwrvrr.  i-  nniici-all  r..niliti..n- a  MTi..ii- ncnrriiirr, 
f..  wliicli  till  |.ali.Mit  niav  -iiiTiiiali.  in  tlir  coiiv-r  nf  a  11  w  IimIii'-,  aiiiiil 
svir.iit.iin-  ..l'  inn-i  pr.  .t',  ,iiih1  aciitr  aiinnia.  l-'..rtnna1(  ly.  -ncli  a  iMiiir-c 
i- .AiTiitiiinal.  In  ■  .r.lcr  ilial  tin-  |iatiiiil  -lionM  tinally  ilir  a-  a  n  lit 
el'  li.inorriiaL;r.  it-  rr|iratr(l  lu'cnnvncr  i-  ncr.— ary.  I  lir  ra-i-  arc 
<-|Mrially  |,allirti,-    in  whirl,  it    In,-  l,rrii    p.—iKlr   tM   -ii.-tain   tlw   |iaticiit 

ill     -|,ii,.    ,,f   , ■,,],!, .11-    1.1—    (.r    IiI.mmI.    lull     wll.i    llrvrftllrlr--    (lir.-    after    tile 

la],-,'  nt'  a  tiw  (lav-  in  r..n-r(|nriirr  dl'  1111.  Niiertrdly  i-eciiriiiiL'  and.  at 
time-,  net  even  in-ofn-e  lirinnn-liarv.  Smli  ea-r-  arc  at  the  -aiiie  time 
-tl-dlli:  evidence  of  the  ureat  dcLMVc  t(,  '.vllicll  the  re-i-t.ancc  cf  the 
tv|ili(ii(l    ]i:itieiit    i-    rctiuctHl    in   c.>n-e(|iiciicc   of  imifii.-c   h,.--   (il    blcdd. 

'   l,.r.  cit. 


SYMI'I'iMS  AMI   (  nMri.KW'IKiys. 


233 


111  l\h.~i   i-.l-v-  ill  wliirh  the  |M!ir!i!  .I'm-  !!■  ■!  'li''  ■iMrin;.'  lli.'  Iir~l  ci,].!!.!!- 

Iirlii>.n-Ii;iui',   llir  clinical   liicliliv    In in.-   al.iliiiiii':l\    all.!..!.       'III.'   -Uill 

jic.|iiin-  a  uaw  |iall..r,  tliciv  i-  r.la\ali..ii  .'l'  lli.'  I'.aliin-,  lli.'  |iiiUc 
lii'c.iiii.-  -mall  an. I  -li.i\\-  -ivall\  in.Tca-c.l  tiv.|ncn.-\  ,  li\i'lily  an.)  .■..1.1- 
II,--  III'  llii-  iMniiiili.-.  an.!  |i..--il.ly  -\nc.>]i.,  a|i|i.ar.  Willi  ill.'  rapiil 
in.iva-.'  ill  iiiil-.-rr.i|ncni-y  ijuiv  i-  w.ii.rallv  a--ii.ial.  .1  a  ia|.i.l  iv.liii'- 
li,,ii  in  liic  li..ilv-tiiii|>cratiir.-.  'I'll.'  .■nr\.  'iia_\  I..'  ..Ii-.tn  .-.I  1..  .Ii.'linc 
t'lMin  III  ..r  II  ( '.  far  ImI..\v  the  n..rinal — |..  :;.">  ('.  ami  li.L.u — in  tlic 
CI. 111-.'  ..r  a  I'.  ^^  li..ni-.  'I'lii-  .■liara.lcri-I ic  inlcr-ci  I i. .ii  ..I  |inl-c- ami 
Icin|..  raliiiv-.  iiiv. -,  ..f  whi.-li  an  illii-tr.ili.ni  i^  -iv.'ii,  is  ,if  ^nivo 
pr. .L;ii..-i-    (  I'iu.    -  I  ). 

jtip.n.Jiic^  u|..iii  ill.' .■.,ii-liluti.iiial  .•..ii.lili..ii  ami  tli.'  iin|nv--i..ii  that 
til,  .|i-,a-,  lia-  ihva.lv  ina.l.'  ii|i,,ii  llic  ,ii-;:ani-iii,  i\.n  -li-hl  li.'in.  ,n-|ia;ie 
iiia\  l,,' all,'n.|.'.l  willi  iii.nv  ,,r  I.—  mark.'.l  .1.  |,iv- i.'U  ..l'  lli.'  IukIx -l.iii- 
l„i-;ilinv.  'ill,'  l,in|MTalur,-.Mirv.'  .if  lli.'  iy|.li,,i.l  |.at!.nt  n-a.l-  in  a 
ivinaiK  il.lv  -iii-itivi'  inanmi-  !.,  In  iii.,rrliai;v  in  !'ar  ;:ivatcr  il.'iiivc  lliaii 
til.'  |iiil-.-,  ulii.li,  in  til.'  |iiv-.n.v  .,r  in...l,Tali-  int.-linal  licini.rrlia-i',  liy 
ii..  111. an-  aluav-  li,-,'i,in.-  -inall.i'  an. I  in,,iv  riv.|ii,nt.  in  .•..rn-|".ii.l.ii.-c 
will,  ill,.  iv.liii'li..n  in  l.inp.i'atuiv.  I  liavc  ..I'lii  .,l.-irv.'.l  tli.'  |.nl-i' 
1,111  liiil,-  inllii.'n.'ci  willi  ivi;  r.'ii.v  L.  tiiln.--.  t.'n-i..n,  ami  lVc.(n.'ni-y 
ul,,.n  ill,-  li.im.rrliai:.'  wa-  m.t  ivimmIcI  ..r  \\a-  l.ut  -mall  in  ani..;mi. 
(iuilc  raivlv   1   have  .'viai   -.•in  ihc  |iiil-i-tVci|n.'n.-v  tiill  parallel  with  ihc 

t.'mpcratiiic-.-iirN. a  c.n.lili  ,n  that  i-,   with. ml  ilmiht.  In  he  c  ,ii-i.lcrc(l 

a-  a  t'av.iralih'  |ir.)'^n.i-ti.-  -iu'ii. 

It  \<  an  inlcri-liiii;  an. I  |iracli.-al  t'a.'t  that  c\cn  with  the  im-chiti'Iico 
III'  |ir,ifii-|.  iiit.-linal  licni.,i'rha'^c  tlu'  c\truvasati,,n  ami  the  cvacnati.,!) 
,,t'  th.'  Ii|.„,(l  c\tci-iiallN-  liy  n..  in. mm-  alway-  taki'  pla.-.'  in  iiiiniciliatc 
-iic.'i--i.,n.  <  )ii  the  .■.iiitrarx",  it  m.irc  ul'tcn  lia|)|M  n-  that  ca-.'-  arc 
uli-crvi'.l  in  which  the  |iali.'iit  lii'.'.mic-  pniti.iinilly  ain'ini.' ami  cina.'iatcl, 
while  ill,'  icmperutiirc   rapi.lly  iledim-   ami   th.'   pnl-e   lii.'.unc-   -mailer 

aii^l    ni..i-e   tVe.|nciu iuii-.   ther.'t'.irc,   .,f   cui-iilcralili-   iiilcrnal    liciin.r- 

rha:;.'  ai'e  pre-ent — ami,  niAcrtliel,  — .  |i.,m-  nr  I'Vcn  .lay-  may  elapse 
Im'I'.iiv    the    ri-nltiiiLi'    lil.„iily    iiili-tinal    .lisi'liai'LT.'    take-    place.      This 

appears  t .air  c-peeiall\-  when  the  lilce.liiiii-p.iint  i-  -itnatcil    liii;h    iij) 

in  th.'In.wcl  ami  l' .■  cxtrava-ati.m  takes  ],lace  -h.wly,  parll.ailarly  when 

th.'    1,1 1    ..,,/e-    tr,,m    ^p.iii.^v    Fever'-    p;itehes    whi.'h    ari'    in    a    state 

..f  li.in.,rrha.:  ;iilHtrati.,ii.  This  e,,mliti.,n  is  al-.>  t'avi>r(><i  liy  fechle- 
II.--  .,1'  iiiti-tiiial  peri-tal-is.  -iich  as  ..cciirs  in  the  coiirso  of  severe 
atta.'k-,  particniarlv  if  -evcral  ci.nsi.leralile  henmrrhaL'f-  hnvc  alreaily 
t  ik.>n  (ilaee.  ratieiit-  .IviiiL''  tV.nn  intestinal  licm.'rrlia^rc  ipiite  yrcmr- 
ally  .1.)  m,t  (>x|icl  the   la-t  |).irti.iii   ..f  M.tod  extravasated.      Under  such 


I 


224 

(■'n'iMiin-l:iI 


71  /■//"//'  / '  1  /  /: 


„.  i-  f, I  .ifin   (l.:illi   lill''l 


..„n,l,n ;,.,,:„■,  K.iv,-n-,.. ■.-,-, In.    ,.l...a!    -:.n.  u.n.K  , 


n -Miiaii. 
I  loll    III     I 


li,.    .l:i-ll.'    1«'M-i..n 


,,|-  th.  alMln.n.n  L.  tli.'  I"''""  "'  ''""^^l'^ 
..„„-M.,i...:i  |..-nli:n'  .ivnml.m-  -rM-:i,P.n  l.-in^  -,.in,..  „:,.-  iini-n-l 
t,,   till'    |i,il|iatiii;^    han.l. 

Tlir  u.ciinvii.T  ..r  nil.  -tih;il  U< 
M.n..u-    .A.m.       !'■  '!"■    I'ati.nr-    -lr..ii;ll 

.li,i„„-,av..rMl,l-.l..r.li.    ti.-.  ii.. nli...  .  .1..-  pl.-i-'"  nm  pn  .■  ...ily 

,,|„„,.,n,l   ,,,„,n..M.      l-nl,nnKi,i,.nTiah    I...1   .  a-.  -   .n,  ...r,un:„..lv. 


„,„i,.iilia..;.'  i^  aluay-  an  iini".rlalil  aiwl 
ll,    |„.    m,,(mI    aii'l    tilt-  ..liifl-  '■"l>- 


lliil     r. 'II1III..II. 


NiM'ltl 


1    lia\c    in    a    l 


iiiinlxi-   ..t    m-tanrt-    -t  t  ii 


,1„.„| nrinl,-~.han-lxl,..u,-an,.r,l„..ir-t    i„.ni..n-tia;:,.,  an.l    .u..'.; 

...,.„    .lining    .iH-    li)M    1 ••       A     l^'-^'l    "-nnina.i....    ...    .1.. --'•    ''' 

,,  ,   „,    ,l„v,.,lav,   i-n...   .■a.v.att.r,v,....i.i....    ..f.ii-    t..'......Tl.ap.       In 

,.n..,al..l':.'lu-l'-i.  ...•■■...-"  ^'11.  '^'l-l'l-'"    -   tli-  .■.....-   "I    '-" 

nnv,.,..iiv...lav-.       iM  -...,..■■ a-.-  .I..a.l.. ..•.■...-  i..  'I-  ' -;  "'   ^'  -■'■  ^ 

,„,„„„„..U,,,;,..v,„    -,.v,.^al^^...■^-,  nn.r  .1,,.  li...n...Tha^..   Iia.   .■...-,..! 

1„    „„.|,    ,..-.-    .■va.ni....i....    '•!•    '1-    1 y   ^''''■'-   '''■^'"'    •"^'^'   ^''7   '■'■''"' 

„„„nn..M.....ial.an.l.li..i.n,..v-..,ni^,ai....l    ,lia,  ti,.  ,.a.i...t.  l.av.  ..... 


IV..II1   tlif   attciida.it    In.-s  I'l 

tl.c 


,li,.,l    .lirrrtlv    tV..ni    tli.'    Ii.in. ..■.iia-c.    la.t 

.,,,.„utl,,    tVo.n    xvliu'li    .l..-y    U...V    ....aMv    U<    .vr„v..r,    ...    >inW   o 

.,.,„.  ,„„,„ii,v  ,V„M>  i....-.iMal  li...n„.-.-hap'  .-.  ."  ^'""'■^'1-  'l'"t.-  .)-'l'- 
()„  ,l„.  av,.,a.;..  iV.„n  -.„.  :;..  ,..,•-,.....  -.Ml,.,..  =;•-<-'„;- 
,i,i,.-Mn..r   ,.1—1    .li.ti,u.va,:U.2    p.T  .vnt..  I....1.-.-....-...    at   ..S  «. 

t   i.  tn....  i-   ....fav..,aMv   inH.....,-.-t   1-  tl.o  i...l..H,...   ..t   a   .......l..r  ..t 

:lu..:J,w:lS..,....-.-..n...;..-I-I.-        1..  Ha.nl.,..-,  1  ....... .............l 

;„Ual.lv  l,.v   .1,......-.  ..:......lv.  ...   .l.-- 
,U„v,.a.•lss7...,.lvll..■.  ,,...-...nt.      Th..-..  ti,-...-..^...."  ......  'l-''--- 

L  ...  aU  ,.hv,i,.^n.  ,l,a,  .....  ....ly  .1...  '-,.......>■.  1....  =a-  ti--^^^^^ 

..f  i„...^,i..al  l. .•-■I.a...   ...ay  va,-y  ..,„.-i.l...-aMy  .V.,n.  as  yet  u„k....vn 

^^„.,,-    a-  a  ......It  ..f  t..n.i....-al  an.l  l....al  ...H...'..-...-.  _ 

'     Wh,.tl,..r  -..K  has  anv  inll...... m1„.  ,.....,....-i-  ..f  -U^'-".~- 

,,,. I,.,.-  n„.  a,.p..ara^  v.,  ...  l-  .l..ti..it..ly  drU.uuurA.      1..  .ny  ..^l.c.^- 
.,„;;  „.  dan.-.-  i-  ..va,..r  in  .....n  ,l,an  i..  won.....      F,-...n   ,1...  .•l.ara.-,.. 

„r,l...   hi Iv    M....l-apart.    ..a,.U-all.v.    in-.u    th.   al...  ....■   an.on.it   ..i 

,    ._a,.n:.„..-ti,....i.l....a..    -vlyl Ltai.,..-!.       1   sh....M,  L.—r. 


.s )  Mi'i'iM^  AM<  '<niri  i<   i//<<\v.  -j-j,) 

(■■ili-l(iir  till'  iil~i  ii.il';.'!'  I'l  iiliiirti  III  IjI'ji-  i-.iiiMiiliili  li  iiiii — I-  :i.  -il'i'iii^. 
Till-     c...!     Ih-    cll-iili  fell    ;i-    illilic:lti\  c-    ..|     rl'i.-ii.ll     III'    ,1     liiri^i-    \.-.-c|,    ;irii| 

|ir"li;ilil\  ;il-ci  tliiit  till'  cpri;;lii  ipI  llic  In  im .itIli;.'!-  i-  ill  llic  Imu.  r  |»iriioii 
i>r  llic  illli'-'lnii',  |i^il'lirl||:ir|\  llir  i'<'|i>li,  llnMi  uliii'li  .1  lii'liiol'iiiaj;!'  i- 
(.ricM    lik(  1\     I"    Im-   t-|HiialK     iii:i--ui'. 

rilr  \  iru  I.iIm  II  ii\  :l  nilllllirr  iil'  ( Ij-t  illi:lli-ll("l  (•lilli<i;lll-,  -licit  ;|> 
(ii;i\c-,'  ri'i'ii--c  iinr  anil  ullici-,  ||i:il  iiilc-l  iii.il  liciiiiirrli:ii;c  i-  imt  a 
-crinii-,  lull,  on  iIh  (uiiirarv,  a  rallicr  lliN.nalilc  ncciiriciicc,  i-  inn-t 
rciiiaikaliic  W  liilc  (  ira\ c-  lia-cii  lii-  •.|)iiiiuii  ii|i<<ii  coiK'i'ctc  in-lancc-, 
the  iti',:ciii.iii-  'i'ioii--(  ail  \va-  Icil  I.,  a  i;cii(  lali/al  imi  ut'  llii-  \  icw.  It 
caiiiiMi  lie  denied  ijiat  iiiudiratc  lo--  nf  IiI.kmI,  oi  i\iii  a  -iiii;lc  c(iii>idc|-- 
alilc  inle-iiiial  liciiinnliaL:c  uliieii  i-  ikiI  i-e|icalcd.  occiii-iini^  in  a  ruiin-t, 
fiili-liioiidcd  [laticnt  willi  liiu'li  t'c\er,  a|i|)cai>  at  time-  tci  inliuciicc  tin; 
^.'cticral  comlilinii  t:i\-.iialiiy.  'I'lic  [(aticiil  tlicii  Imchiik-  bfii^iitcr,  the 
Ieiii|ici:itiirc'  decjini-,  wliilc  tile  |iiii-c  rciiiaiii-  ir'"'il.  h!\  ell  tllc  -plccll 
'lliilcitriM'S  di-tiilct  fcdiicti.iii  in  -i/.c  (  iMclilmr-t,  (  iii-ciiinalin ),  and  it" 
the  occurrence  takes  |ila<'e  in  llic  tcriiiinal  -latrc  "i  the  di-ea-e,  cdiivah'S- 
cinee  may  at  oiicc   -et    in.      A-   ii|i|io-ed    tn   -ndi    mrc  c\(e|)tiiiii-.   is  tin- 

iiM'i'w  hcimiii^'-  |irc]>.  ■nderaiK f  niil'a\  •■ralijc  ii-nit-,  -(,  that,  e\  cii   tVoin 

the    most    la\(iral)ie    a-|)eet,    tl •iineiici'    of    hcniorrliajre   cannot    he 

looked  upon  as  a  desii-ahie  event.  It  -li.nild  licie  atrain  !)<•  pointed  out, 
and  cannot  lie  too  -lidnt:ly  empha-ized,  that  e\eii  di-tinuni-hed  writers 
ot'teii  base  their  eonclii-ion-  ii|Hin  in-ntlieieiit  statistics.  I  have  noted 
periods  in  which  only  2  of  ol»  successive  cases  of  intestinal  hemorrhai^c 
miller  oli-ervatioii  teiininated  fatallv. 

Peritonitis    is    oi f  the    imto\vard   occurrences    in    the  course  of 

typhoid  tevef  deser\  iiijr  of  detailed  eon-ideration.  It  may  remain  cir- 
cimiscrilied  or,  as  is  imfortimatcly  more  common,  it  mav  lie  ;rener:il. 
In  the  l.iruc  in.ijority  of  cases  hotli  varietie-  oci'iir  a-  sequels  of  the 
inte-tinal  lesion.  It  is  the  I'ontaminatioii  of  the  peritoneuni  from  the 
int<'stinal  ulcers  i)y  the  excitin^r  acrcnts  of  intlaminatioii  or  the  esca|K' 
ot  inte-tinal  contents  into  the  alidoiuiiial  cavity  that,  in  aceordaiieo 
with  s|M'eial  conditions,  irjves  ri-e  at  times  to  circimiscrilu'd  fo<'i  of 
intlammatioii,   and  at    other   time-   to  L'-i'iiend    ))erifonitis. 

The  iiiHammatioii  of  the  peritoneum  is  hut  rarelv  independent  of 
the  -pccitic  le-ion-  of  I'cyer's  patches  and  the  solitary  follicles.  Now 
and  a;raiii  piiij:rene  of  the  howel  from  some  other  cause  mav  he  the 
nndeilyiiiir  tiietor.  'I'liiis,  in  one  instance,  I  noted  such  a  condition  to 
lie   caii-td    Ity    thronihosis  of  the   artery   supplying;  that    jxinion   of  the 

'  Clininil  I,fi-ti(ri-s.   1S4S.  v,.|.  i. 

'•'  Clin.  )ih\/.,  L'cl  cil..  irari-l,  l.y  Kiinztiiiinn.  vol.  i..  p.  238. 


I 


226 


7)  iii"ii>  1 1  \i  i: 


i 


% 


1h,\\.  1  :in>l  ..f  ill.-  :ir.-.,iii|iaiiMiiL'  \'  hi-.        I '.■rl'..r:ili.  .n  ..f  ..ill.  r  ,.|.;:iii-  :il-n 

,,|;|\     ll(       lllr     ■Mil-.      ..r     |..   ril..lllll-,    J-,    I.T     i  1 1 -I  :l  11.  .  ■,    II 1 1  ll  1 1 1.  ■    .  .f    I  1 1. '     -|1..M 

,,r  ..r  ill.  III. -.111.  II.'  -I:ili.i-  in  .■..n-..|il.n.-.-  ..f  -..I'l.  iiiii^  ••>■  :il. -.-.--, 
lUllllllv  ..(■  ill.'  -.lll-l.l:i.|.l.  I.  .'I'  ill.'  l:lii;.l-  l.ili:i|-\  |  .:l --:l-i  -,  "r  .||:IM 
ulwMt"*!"  .'I'  ill'  li""'!'  "Ili.'li  ll-l-  .1.  \.  I..|..  .1  ill  ill'  .■..III-.'  .•!'  ill.-  ilUil.'N 
..('    I\  |.I|M|.|     I.  A  .1'. 

I'll,  ,, II.  -I i.. 11  ,1-  I.,  will  ill.  r  :i  I'i.  .ill/.  .1  |M  ril..iiili-  iiKiv  .M'.-.ir  ■.',  11I1..11I 
|.rl'r..i';ili..ii  li:i>  I... '11  r:li-..l  l.>  <  u-liiii-,'  uli..  lliiiik-  llial  III  ..iiaili 
CMH-  till'  .'Mi'li. -I  -\  iii|.l..iii-  ..I' I"  rti.i'iili"ii  iii:i>  I"  .lii.'l"".-i  liltl.-  I.-  il 
\/,A  iiitl:HHiiiali..ii  ..f  ill'-  -i-r.-:i.  "iili  >■<■  "llli'.ui  ill.  |.a-a.^'i-  ..f  iiii.r..- 
..r-aiii-iii-,  an.)  l.a.liii'^  1"  a  -li-^jlii  a.lli.-i\.'  |..  lit. .nil  i-.'"  Tin-  In- 
-■.,ak-..ra-  ill.'  |.i.  |..rl'..iali\.-  -laui'  .'I'  ill.  .rati' 'ii.  H'  in.-iiti.ni-  a 
.a-.'   ..f   Miii|.li\'-  ■    ill    «lii.-li    ill.  I-.'  v\a-   |»  ril..iiili-.  I'Ui    il.    |"'rf..ral i. .11 

t; I;    :iii.i    al-..    "1  .a-.  -  ..r  '  iainlii.  r'-,'    in    \slii.'li    t'alal    |>.-ril.iiiili-    ...•- 

i'iii-r.-.l  uilli..iil  an  :il.-..liil.-l>  ...iiii.l.l.  |m  rr..iMli..ii.  '!'«..  <i'  ili.'  ."i-fs 
r,'|„,rt..|  l.s  S|,allii.-k.  Warn  11,  aii'l  <  ■-•M.  '  ^miv  -ai.l  |..-li..u  al  .,|..ra- 
li.iii  "a   i;.'iicral    -.|.li.-    |.i'ril.  .nil  i-.  .  .riL'"iiianiiL''  in  .iaina:;.'.!  an. I   ii.-.-r.'-i'd 

:irra-  ..!'  |M-|-il..ii('iini  ..\ .  i-  lli.-  La-.'-  ..I' ii'.n-  '>  pli'ii'l  nl.'.r-." 

'I'll.  |„-i'il..iiili-  a--...'ial.'.l  uilh  ill.'  -|M.iti.-  l.-i.'ii  ..f  ill.-  iiil.-tiiu'  i> 
II. ,t  ..iil\  ..11.'  ..f  til.  111.. -I  t'r.  .|ii.  111.  lint  al-..  ..11.-  ..l'  tli.'  111. .-t  .'liai-a.-l.-'-i-li.- 
.■aii-i-  ..r  a  -n.l.l.'ii  .iaiii:.  n  .11-  ami  liilal  .liaii-.-  in  llif  .■.mr-c  ..I'  an 
atta.'k    ..r   lv|ili..i.l    I'.-v.-r.      'I'li.-rr   an-    v.-rv    I'.-w    ..lli.i-    a.-iitc    iiili'i-li..ii- 

iji-.a-.--    in  wlii.'li    llii-  (•..iii|ili.-ali..i ■m'-   at    all,  ami   I'V.ii    tluii    ..iily 

a~  a  raiitv.  At  liiii.-  |i.-rt'..rati\ .-  |i.-rit.iiiiti-,  like  iiili-tinal  lM-in..i';'liai;c, 
i-  till-  lir-t  .li-lini-li\.'  iiiaiiir.-lati..ii  in  a  ca-i'  ..t'  aiiil>nlal..;-v  ly]>li..i.i 
ti'MT  |in-\  i..ii-ly  -li.iwinir  ii.'  -\  iii|it..iii-,  nr  at  Fii'.-t  attcii<li-.l  witli  ..l>-.airr 

(li-tiirliaii.v-.       'I'll -.1-..,,        ■-    11.. I    y    ill    I'ai-i',  -.1  that  if  iii.livi.lilal- 

witli   |i.  rf.iiativi'   iM-iit.iiiiti-,  L;i\  iiii:  an    nii.'.-rlain    lii-l..iy  nr  11 •  at  all, 

an-  a.iiiiitt.-fi  t.>  a  li.i-|.ital,  tlii-  |M.-il)ilily  -I1..11M  .-[..-cially  1»-  kcjit  in 
mill. I. 

I  have  nhscrv.'.l  <w»'s  in  whi<>h  tho  flr>t  r^yiiiiitoiiis  of  peril. .iiitis  (.o.urml 
ill  |Krs.m,^  wh..  Iia.l  licai  iir.-vi..iislv  a|.|ian-iitly  h.-altliy  in  the  lonii  ..f  iiit.-s- 
liiial  .-..lie  or  suil.lcii  ciillapsi'  uhilf  walking:  ahoul  or  while  at  wcr...  A 
case  iiii.l.'r  ..Iwrvatioii  was  hr..ii..:lil  to  thf  li.i>|.ital  a,-  on.-  ..t  v..lviilii.-- : 
aiioth.T,  iin.ler  the  sii>|.ii-i.)ii  of  haviiii:  attfiuplnl  -ui.i.lc  with  ai'scni.- ;  an. I 
a  liiir.l.  a-  a  ca.^i-  "f  iiicat-iHiismiii..'. 

Th.-i-  <|iiit.-  -nrpri-iiiL'  :iii'l    "It"''"  n'""' '-'■ni^"'"'   '"i^''-  :""''  •■oiii|';ii':il'l'' 

with  ih..-.'    in  win. -h    lli.-   -yiii|.t..in-  ..f  -.■iirral    |Mril..iiili-   .i(-v.-l..ii  mhI- 

*K,vu,  S„n,n-ol  '•■'"■/'''■"tin,,.  „„■/  S,:,.„l.<  „/   T,i,,h„;,t  ferrr.   IMiila..   1W.'>^.  ].    S.-.X. 
'  fllnKf!""-  M'll-  .Iniir..  V..1.   xhi..   |.    1  U. 
•  li,,f,.,i   M,,/.  am/  Sura.  .Imi\.  .Jlliu-  "JH. 


..^f ' 


*{^<^^ 


lii! 


^^\ 


In 


228 


IcMirr  ;    1" 


i-ldVatloii     li:i 


'ivrii'iii,  I  ivi.i: 


li:i-    lii'cii    iiMtiil    r\(  11    ill    tlic   rt'ciinii    liy    variolic 


1\  r    hUt  w  !-<■    i>l>-.  r\i 


writi  r-,    aiiil    ! 
traii-vd'si' cdlon.  lioWiAcr,  a|i|ii.ir  'i'  !"■ 

tli 


:i-iii\(liri'j     ami    the 


tlir  lavniTil  -cal- 


.f  llic    It  -i 


Will 


I    lii;anl     Id     lllllc.   Illr   iM'clllTrllfl'    i 


if  ixTtiiratii  II  c'liiiiciilo   1-1 


.aalh"  \\itii  thi'  |"iii"l 


,|'  (•\|..lialh'ii  dl    I 


\\f  -Idiitili-.       It-   larli 


i-    ,-d    trcullrlllK    llld  i"l- 


iilli    liciiidrri; 


rr    dccill'- 


rMfcliirh    rare, 


(I  rt-iilt-  ciiilv    iiiuli'i- cxftplidiial    rdiiililidii-.      'I'lic    |)riiiri|ial    liincldi' 
t'  iifrt'dralidii    i^t'  \\\v  liduil    i-    llincl'drc    iIhcihI   dl'  the 


tlu'  iicciiriciicf 


1 

(I   anil    llid    tl 


•  k    di'   tlir    ili-ra-r.       A iiatdiiiic    invi'-tit;al'dii 


111'.-  that  tlir   arriilnil    dci-iii-   i-|Mriall\    wlini  tlir  iiiiiliillarv  iiitillia- 


ti'ai 

lidii    i-    iiid-t    I  \ti  ii-i\r,  ami    rMiinl- 


ijdw  II    Id  ihr    |M  riti 


■lirlllii,  iir  r\rli 


iii\dlvr-  till-  al-d.  Ill  till-  way  tlir  tlddr  ..f  tlir  iilcrr  may  rdinr  td  lir 
fdi-iiiril  liv  a  traii-liirriit  iiinnliraiir  a-  thin  a-  |ia|irr.  that  uill  hf  iinahlr 
Id  with-tanil  r\iii  ihr  -liirlHr-t  nirrhanical  iiitliitiiri-.  In  >diiir  ra.-r- 
tlu'  i;;tiltratidii  ,,ml  llir  -Idiiuhinj  arr  -i.  ilii|i  lliat  ill.'  iMrildiiriiin  alMi 
i-    iii\dl\ri|,   ami    rii|iliirr   iii-nr-    ininn'iliali'ly    ii|idii    thr   drriiiTfiicf   "t 


uiiLiliinL:. 
il 


dt    thf  iilrrr-,  a  L;ria 


111    tlir   ra-r-    jii-I    ivfiTVcil    t",   ill  u  Imli.  altir   rlrarint;'   n|i 
llv  ihiiinni  aiva  in  tlir  iiili-:iiial  \\all  nniaiiir-,  jht- 


t'di-atidii    taki-    [ilarr    lithi  i'    thi'dn^h    niplmv   di'   ihrdiiiih    innri'   or   li>s 


■  railnal  rxtni-idii  dt'  tlir  iii.i 


■ralisr  |irdci--. 


'riir  latlrr  diTlir-  i-lina; 


hii-h   thr    iiiTitdiiili-  ilrvrld|i-  lair — at   thr  rilii  dt'  tlir  lliild 
th   wrrk. 

•trr  dt'  thr    ri-nlliiir-   d|iriiinr    ilr|irmU    ]iartly    iipdii    the 
■liiiiiiiarv  altcratidii>  ami  thr  iiidilr  d|'  .lrvrld|iinriit  dftlir  iird'uraiimi. 


Ill   ra.-r-  in  w 
or   ill  thr   t'diii 


'1" 


ir   rliarai 


riir   iHTtdralidii^   iliir   td   lai-p'  ilinrt 


SII 


I'll    attain 

■nrrallv  altrilnitahlr  |i 


it'   -triirtnrr,  \vlii( 


Il    I 


iliaiiirtrr   dl'  fi-di'i  a  i|iiartrr  dt'  an    iiirli    td   diir    mrh,  arr 

the  I'xt'dlialidii  dt' lai-iii'  |irdt'diiiiil  -|dliurli>,      Thr 

Iviiii:  rld-r    IdMrthrr  ill  rini-iilrralilr 


nail    rriliritiirin  diirninLr-,  ;it  tinii" 


iiiiK.hrr,  arr  dttni  rrtrralMr 


td  -ld\\  Iv  ])rdij:i'r--ivr  11 


Irrratidii.  whilr  nipt- 


illlr  t 


nrr-  illlr  td  inrrlia 
liavr  lirril  alilr  ti 
lit'    the    dnrllillr'-. 


lliral   illllllrllri-  arr  dtli'li    ( 


li-tinL;iii-hril,  a-    1    think    I 


i\V,    I IV    t 


hr  1.     -iliiilinal,  -'it-lil<r,  rartinl  rh 


Aiiidiit:    thr    iiiirliaiiiral    intliirnri  -    rivii 


\\r       Y\-V       Id 


ruiitiirr    dt     thr 


l,.t 
:aM'dii-  ili-trii 


at     thr    -iluatidii-    anatdinira! 


irrill^lid-ril     i> 


|il'rill^| 


lidii  (if  ihr  inlr-tinr.  i'-|M'rially  il'  it  nmlri'iid  -mliini 


iiii;- 


luriitatinn  in  a   -m 


due  til  dtl 


'Ir  lidrlidii.        l'"lirtlirr,   thr  rdiiilitidll   i-  vv\ 


taiiilv  dt'ti 


lllv    thd-r  r\rrtril   liv  thr  -dliil 


irr  liirrhaiural    inlliimrr-,  r<|>rria 
1  rdlltrllf-.       That    -till   ullirr   nirrlKiniral    illlllinirr-  artilli;-    t'l-dlil 


iiiti-<tiiia 

within   anil    wltlidiit,   siuh   a^    vmnit 


||l<r.      Ion  •I'll 


llldVrinrnts,    r.-|li'r 


r  '/rttiiiL'  n|).  \  idlriit  rx|)iil-ivr  rtViirts  anil   str; 


till)  early  sitlinuf    nj'   '" 

'm\i  at   -tddl   ami    in   i!ii''tnritidii.  nia\    rvrrt    an    inin 


lll|(rrllrnilril    I  lirdrrtirally .  aii'l  thr    I 


ridii-    rtVi'i't,  ran    hr 
1  tlir    Ud— iliililN    dt'   thrir  r\i'rri>ili'_'-  -nrh 


.v)'i//'/'*.i/^  .i\7'  <'iMfiii\nii\.' 


229 


••111  MctiMii  i-,  mil'drtilllalcly,  tun  (illcii  (lciniiii-.t  i-atc<!  ;it  tlir  hrd-iilc. 
I  )i.  I(  til- rn-iir-,  wiili  -r(.,ii.hirv  ira-tm-iritr-tiiuil  cat.cirli  aii<i  aliiioiiiiallv 
iiici'ca-iil  |>ri-i-tal~i-,  all-  with  (■(|iial  |ii'ii|iricty  \n  \h-  lirld  ri-piiii-ilplf 
in  rcrtaiii  I'a-c-.  All  tlir-c  ]Miiiit-  caiiiKil  !«■  tdo  i-lcai-K-  |<c|it  in  luiiid 
li\-  llii'  Vdimjr  |iliy-irian,  in  m-dcf  that  he  iria\  a~  t'nllv  a-  |)o--.il)lf  ,-hirld 
hi-    |iatii'Mt~    trniii    iiijiiiy    at    a    cfitical    |ifiiiid.       While    in   a    \\w  ca-cs 


i|ifnn'  niii-t  im-vitaMv  take  |)1; 


ICC  in  consci 


|ncncc  cit"  tiic  extent  and  th^ 


dc|)th  lit'  the  nlccrativc  |ir'oee->,  in  the  nvefwhclniiliL;'  inajufitv  iil'  ea.-es 
the  ciinijiliiin-  are  tiiitnnatcly  -iich  that,  niider  the  niii>t  tiivni'alik'  eif- 
ciiin-tancc-,  uitii  cafcl'ni  nli-civatiun  ot'  internal  ;iiid  external  prccaii- 
liiin-,  e\cii  dce|)  iilecration    iiiav  iniderLTd  eicatri/atinn,  and    c\'en  niiiiuto 


■rliiratiniis    niav 


reiideri'd    harnilc---    liv  tinicl 


y  adhe-iiin  with   a<lj:i 


<'ent  iiriraiis.  It  i-.  a  |iarticnlarly  di-tnrhiiit;  tact  that  |iertiiratii)ii  inav 
rtill  take  place  at  a  late  -taj^c  ul'  the  diM.i-c,  alter  the  n>iial  period 
when  exf'iiliatii)ii  (if  the  slonuh  i-  ciirn|)leted,  and  even  at  a  time  when 
the  patient  appear-  alnm-t    ennvaleseent.      This    nidiirtnnate  accident  at 


tnnc-    iiccnr-    in 


!• 


|iat( 


|-ecl'llile-ccnce 


t'  the  speciilc    le- 


nd  -iililary  t'ullicle-   wl 

th: 


lleh    exlllblt  a 


I'lii-  at  a  tunc  <.\  hen  ttie  inayiri 


it\   iif  th 


nicer-    arc    ni    prnee--  ot    licaliiiL''  nr    li 


tmn. 


i\c  alreadv    and 


I'ririine  cicatriza- 


Illii-c   \M 


In   other  ea.-e-    iinpcitcctly  eicatri/ed    nleerated    areas,  especjalK 
th  \'cry  thin  llooi-,  may    siili-cipicntly  reupcn  and    iindertro  per- 


tiiralii'ii.      l-"inally,  the   indclinitcly  protracted    -n-callcd    sliiirjri-li   nl< 

may  !»■  a  -nnn ('  c-riat   daiiLi'cr.       I    luixe,  l^r  instance,  ohserved    per- 

t'orativ  periinniti-  develop  all'  r  the  lif'tieth  and  the  sixtieth  dav  of  the 
disca-c.  in  mic  in-tanci  c\en  at'ti-r  the  hundredth  dav — a  warniiii.''  tor 
|)alicnts  and  their  friend-,  who  often  charire  the  physician  with  pedantic 
rigidity  of  supervision    diirinn:   eonvalcsceiiee. 

Siii-li    late    |)»'rfiirati(iiis   are    cmpliasi/eil    also    hv  oiher    writers,  iiaiiielv. 
Louis,  Mnrchisiin.  (  " 

siiitrer  considers   llic   shiir^risii    uli 


iricssiiiu'-er,   Nieiiieyer,  and  ollicrs.      Aiiiotii:  these,  (Iric 


liihty  ot   perforalion   exists   llironi:hout  (piite   a  Ioiil'   t 
tiillowiii^'  tiirures: 


is  espeeiiiliy  (lanireroiis.      Tliat    possi- 
iine    is   siiowM    hv  the 


Of 


I  ■)  cases  o 


f  perforation   that    I  have  analvzed,  this  acciileiit  oeciirrei 


iielw  11-11  the  eleventh  and  the  twentieth  day  in  '_'•'!,  from  the  twentv-first 
lo  the  tliirtii-lh  day  in  :!1,  from  the  thirty-first  to  the  fortii-th  dav  in  l:!,  and 
after  the  firtielli  liav  in  »>. 


rile  fi-cipiency  of  pertiiiation  of  the  howel  may,  precisely  like  that 
ot  inte-tinal  lieniorrhatrc,  he  extremely  vjiriahh  at  ditfercnt  times.  I 
have  oli-ervcd  epidei 
others  in  which  tl 


nics    in   which    the   condition  was   (inito   rare,  an 


.1 


le  cases  were  execedmirlv  common. 


I" 
This  fact  prohahlv 


•xi>l;iins    the   e^  treine   divcrsitv    in    the    stat<'ments    of 


\ari(ins    writers 


)n    what    th  s    temporal    variation    in    fre(pieii(-\    depends    is   as    yet 


rvi'iinin  II.  vi:i: 


M« 


I 


m 


iinkiK.wn.  Tlic  .IfLTcc  U>  wliirh  tlic  iiiiinlMr  ol'  ■•as.-  of  |>rrl'(irati(in 
may  at  tiim-  iiima-r  i.-  -Imwii  liy  an  aiialy>i--  liy  Murrlii-oii,  win.  imtcd 
[M  rtliratinii  in  -JI.J  |mi- cml.  arnniiLf  ln:,  Mnti'p-ii-  in  ca-c-  <il'  lyplioul 
frv.  r.      Alihun-h  H(-.-lii'i  '  oUmtvcI  only  .M;  ca-.-  of  iMTti.rativc   jxTi- 

toniti-    (1.1    l»'i'   <Miil.)   a wj.    1-71    anlci|iH(>   .inrin-'    tlir    year-    fnitn 

\s\^\  tn  isr.i,  thi-  mnnlicr  i-  <li-liiHily  li--  tiian  that  nsnally  cn- 
countiMvil.  llrdnanl.l  and  'I'lKiinni.-  who  analy/«'il  17-' I  ant(ii»irs 
iioin    Knuli-h,   Ficn.-li,  ami  <  ifrnian    -onn-c-.  timnii    |icrl'iirali<iii    in    lH" 

,.;,,, 11. ii:;    ptT   .'I'm.     (;ri(—ini:<T   nuicd    iieiforatiun    in    It — ll.nl 

.„,,•    ,.,.,,t. of    lis    antoji-ii-     mad.'    hy     hini>clf.       I     have    pcr.-onally 

,,1,,,,,-vcd  ;•:!  cax-: It). 17  |ifr   cinl. — anioni:  'u'\    antop-ics  ( lland)ni'tr- 

Lcip-ic).  It  will  thcrcfoiv  not  he  an  f\ai;i!fratioii  to  a~-nnic  that  in 
tVoni  !•  to  \-l  |MT  'fnt.  of  all  fatal  ra-i-  of  l_\  [ihoid  fiVcr  death  fr-nlt-; 
tVoni  |ifi-forativf  |irrit<jniii-. 

'riic  |i.i-c.iita-v  of  death-  dne  to  ]ierforation  in  the  .I.ilin--  llo|ikin-i 
Ho-|iital  diirinii  the  |.a.~t  ten  year-  i-  eon-iderahly  iii-lier  than  lhi>.  Of 
(i:;  dealli-.  'JO  (;'.!. 7  per  lent.)  weiv  i\\\v  to  |ierforatien. 

Kortunatelv,  tln'  ali-i'hiti'  liv,|nenev  of  |ieit'oralion.  niakini!'  allowance 
\\,r  tciniioral  and  indi\  iihi.il  variation-,  i-  di-tinetly  le--  than  that  ol 
inte-tinal  henionha-e.       1   Im  lievi'  that  nn<lei-  the  nio-t    imlavoraMe   cir- 

enin-tanee-  ]..rfoiation  ra-  in  not   more  than  :'.  |>er  eent.  ot    all    ea-es 

,,t'  tvphiM.!  lever.       In  m\    Leip-ie  -lati-iie-  I  Hi'-'';  i)atient-)  the  pi-opor- 
tion  wa-   -1:1    jwr  einl.       in  llamhnri:  it  wa-   l.i;  I'ei'  <vnt.  aniono-  -lii;i4 

patient-.      The  e-timate  of  (  nie-inucr.  wl h-erved   perforation  in   14 

j.,,..;,.^ •_>.:    pir  eeiii. amoni:  lit'O  of  typhoid  f.ver.  i-  in  aLrreiiiient  witii 

my  '<-■    . 

Amonir  S-_>!t  ea-e-  of  tvphoid  liver  in  the  John-  llopkin-  llo-pital. 
there  were  •_':'.  (2.7  per  cent.)  ea-e-  of  perforation.  Twenty  of  the-e 
were    fatal,  and    :'.    reeovei'ed    follow  int;-   .iperation. 

A<:<',  -e\.  and    -oeial    eonditioii    do    not  o<-ea>ion  -neh  marked    ditVer- 

en.v-   with    r.feivn.e   to   the  dan-er  of  perforati..n   a-   - h-erver-. 

njion  the  l.a-i-of  an  in-al1ieient  nnml.er  of  <-a-.-,  ^tate.  In  ^neral  the 
conditions  are  analom,,!-  to  tho-e  in  i-onneetion  with  inte-tinal  lieni- 
orrliaL^'.  1  helieve  that  ehildivn,  e-peeiallv  nn.lei-  \\\v  a-e  of  ten  years, 
are  le<-  .■ominonlv  attacked  than  adult-,  and  I  l.a-e  my  opinion  hoth 
iiixiii  a  rathei'  larL^e  per-on.il  e\pcriencc  and  npon  the  -talement-  ot 
T.>pin,  iJillict  and  I'.arthe/,  Kocher  and  lleno.h.  The  prohahl.'  rc,a>on 
fur  tin-  i-  the  iicnerally  -liirhter  inten-ily  of  the  inte-tinal  atVection  \\\ 
chihlren,  which  \\\\>  already  iieeii  mentioned  in  the  consideration  ot 
1  y.,,!  ,/.  ii,s,ii.<.-h.  .1  .\r,-i,  .    »■,.■„..  iH,->;i. 


SYMI'I'dMS   A.\I>    (nMI'l.lcMI'/y.s: 


m 


lirllliiiTllIlLrt'. 


;iirc  ;iri'  ('■■IKM 


AliiDiii;  Miliiit^,  tliD^c  lictwicii  iii.'litcfii  Mild  forty  yc:irs  nl' 
iallv  ]ii-((li>iMi-.cil  to  |>('rtor.ilioii.     .\tl<|-  tlic  loiticlli  \  car  of 


life   tl 


ic  occiirrt'iK'c  IS   iflativclv  u 


lati 


COIIIIIIOM. 


he  coiitiarv  oiiiiiion, 


illv   cxprcsxd,   tliat    later   lite   is    in   turn    more   iiredisposed,  i? 


iKit    III   aciori 


I  witli    iiiv  exiieriiii 


111    ireiieial,    iiicii    a|i|Mai-    lo    lie   attacked    hy    |H'rforation    more    fre- 


itiv  tiiaii  women.      'I'lii-  i>  liv  ii(i  mean 


pendent  iipoii    ine(|ii: 


ilit\ 


the  develo|)nielit  of  the  >|>ecific  iiitc-tinal  icsioii>  in  tlie  two  >exes, 
It  prohalilv  M|.on  tlie  fict  that,  with  e(|nal  eliamo,  men  are  more 
itiivorabiv    iiiHucni'cd    diiriiii,r    I'onvaleM'cncc    by    reason    of   previous 


dcrail;r<'mi'iit  "t    the  di<_restive   apparati 


due   to  <liet   aii«i    mode  of  liti 


liian  are  women,  and  often  ai-o  ii 


IV  eominir  under  treatment  late,  as  wel 


as  liv  lil-eater  impatience  and  I'arele^sncss  duriitj,'  convalexmce. 
\\'ith    rejiard   to  social    po-itioii,  perforative    |K'ritonitis  nnd( 


I'ltedK 


I'lirs   I'atiier  more  treipieiitly  ainoii;^  t'l''   |>oorcr  cia-^e>,  jirohahiy    lu 
ii-iiiucncc  of  the  less   favorahle  conditions  oi'  livini;  and  of  nutrition 


aiiioiitr   these   classes,  a 


in'    also  oil  account   of  the  Ic-s  etlieieiit    iiiiisin)^ 
ire  devoted  to  them.       This  is  in  accord  with  mv  ol)>ervation  that 


the  occnnciicc  ol    |)erioration   is   more 


freciiieiit    anioiii;-  ainhnlatoix-  and 


milder  ca-e>    in   the   poorer  < 


rlasso. 


M 


urclnsoii  aiK 


1  (iries>iiii:er  proliaMv  emphasize  iimhilv  the  jireiloiiiinaiice 


it    perloratinii    m   tile   male  sex.      1  have  iiotcil   | 


itc(l   iieriiMJs  in  which  this  ilitl'cr- 


nis,  II.  ttw  vca 


r  l,H,S(Vl,s,S7 


ihicli  1  appreciate,  was  not  present.       Tl 
ilainhiirir,  hotli   sexes  were  ati'eeted   ahimst    iMjiially,  and   in   the  yer.r  1M87 
leinales  evi'ii  soniewliat  more  frecph   illy. 

Symptoms    of  Perforation. —  Tlu'   complication   often   occurs 

iiuite  siidileiilv  and  unexpectedlv,  without  nrevioii-  iiote\vo'*liv  iniiirions 


.\t  times  it  is  iireiH'dcd  liv  more  or  le--  ill-<iei..,ed  disturb 


anccs,  iiainch',  iiierea-e< 


1   alidominal    tei 


ii^ion,  colickv  |)ain,  borborvc^mi, 
and  diarrhea.  Intestinal  hcmorrhairc  of  (rreater  or  less  amount  is  not 
rarelv  an    indication  of  impendinu   breach   in    ciiiitinuitv.      That   this  is 


not    rare    i-    -now 


dini;' 
n  bv  the  fact   that  of  :W 


■s  (if  |K'r(bnition  in  the 
•  lohn-  Hopkins  lIo>|iital,  I!  have  been  preceded  or  aeeonqianied  by 
liiiiiori'hair<'.  'I'hc  tinu'  when  |H'rforation  oeciirs  is  at  times  ipiite 
dctinilcly   stated    by    inteiliireiit    patients.      They  complain    of   stiddea 


-tabi 


liilmiiT   iiani,  or  even  ot    an  a( 


■tiial 


if  laceration. 


In  the  meat   majority  of  cases  the  |H'rforation   is  so<in  followc^l  hy 
doiiiinal    pain  oi'  rapidly   progressive   intensity,  which  can   be  reeoo- 

s,.l 
1 


iii/cd   as  due  to  peritonitis   from   the  fact  that   it   is  jrreatiy   increa 
"II    bii  athiiiii;,  on   passive  am!   active   inovcineiit.  an 


Kl   on    pressure  aiu 


I 

ilpalioi,    ot'    the    abdomen.      In    some    eases    the    patients    refer    th 


2;i2 


ryrii"!!'  1 1  vi.ii 


IKiiiit  c.r  orin-in  (,t'  tin'  ywrn  tn  liic   ri-iii    'h\  |i(i-;i^ir   iiii. 


iir    |]ia|i'lii\ 


i(i\\c\cr,  AYv  niKi 


1,1.   1..  il.-ii:ii:ilc  ;iu\-  ndiiiilr  -ituii' loll.      >iniillt;iiu.,ii.-ly 


wilh    llic-   "11 


-cI    of   lli^ 


lin.   riT'iiicii 


ll\    lAili     |in  rcdiu;.'    It,   tlicf     cicclir 


,li-,iif--iu--   ri'tcliiii^  Mini  v.'iiuimi:',  ii'       '    ■  i|iuiicc  " 


t    wliicli  ihr    ^.i.-tiic 


iiitiiit-.  N\  liifli   :irc    Miiirc  or    li 


llic    lliu'*'-'  1    1"  ^\ii 


ich    til.'    ;H-ci(lrUl  w 


\\  chaliuiil.  :iMil  ot'lcn  niiitain 
ai'i'   (A Mriiatol.      SiHiii  iiiilv 


-iiiai'  am 
iiiir  rcii'liiiijj 


lllnmil-    "I      IIIIICOK 


l>il 


i(jii>  inaltcr  ai<'   cx] 


II.  .1  with  the  ili>tiv>s 


The   alidmn.  H    ll'iw   liicoinc-    | 


t.l    an     CNtlTllI"   il.'./V.'. 


r.ii:r.  --i\cl\   innvi'  < 


that    tlic  (■iilanf..ii-   cov.-n 


li-tcinl.  <1,  at    time- 
ly;  ..I'  tlu'  :ili(l.iiiicii 
li    anil    Ldi>tciiiiitr.      'llic    iiiarkolly    clcvatcil    ])(i>iti..ii   nt' 
the  (liaptii-a.jin  tli.Tfliv  iiiiluccd,  in  ciMiiiiictioli  witii  tlir  |.(rit..iiitic  jjain 


ajiiirars    siiiont 


illv  iiilfrlir.s  with  hivatiiiiitr.      'I'hc  h.iwci-  aff 


11\  (■iiii>li|)at<'<l 


tV.ini   the  .iiit-.t    an. I    i-cn:,iiii   ^o  ;   a 
if  at  all.      Tl 


l-o,  flatus   is    |)a»c(l   U-s  fi'c.| 


lirlltlv, 


iii~r  111    tiif-c  ih-tui'liani' 


li'  tlic    intf-tmr,  -"."III    attain- 


haniM'>.  tlic  iiafc>is  of  the  iniisciilar 


I 

(let;, If  of  intcii-ity.     'I'iii' 

v.Miiitiiii:  II"'  i-aivlv  a..|uiiv-  a  fc.'al  (•tiara<t('r,  >.-  tlial  tlir  ciitiiv  coiKli- 
ti.pii  ,-iiiruot-  the  (Ai-tiiKv  ol'  ilfiis,  ami  for  wiii.-h  it  may  indeed  he 
inistak.il  hy  tli..  c  of  limited  eNperi.'iiee.  Althonf.d,  the  .-yinptoiiis 
deM'i'il)ed  are  ir.iieiaily  attrihnte.i  t..  tlie  iierit..niti-  alone,  at  times, 
esiM'cially  wIk'Ii  the  |k  rit.,niti-  pniee-  ..riui nates  in  the  vicinity  of 
the  ileocecal  valve  aii.l  the  |..wivm.>st  porti.Mi  of  the  ilenin,  and  is 
partieiilMfly  ]o<'ali/c<l  in  tiii-  Mtnati..n,  theiH'  may  lie  actual  occlusion  of 
the  luiiien  of  the  howcl,  and  tiiu-  tn  .■  il.u-. 

The  L^'uei-al  coiiditi..n  ..f  the    patic.'t  .■haiiiies   appn.xiinatcly  in  eor- 

res|Hiiidcnee  witii  the  1. 1  manifi-tali..n-.      'Hie  f.atiires  hccome  draw  u, 

the  no>e  ii.'inted.  the  extivMiitic-  livid  and  <'.ild,  and  the  face  and  the 
h,,dv  are  ..fteii  COVC1V.1  witli  c.ild  -wcat.  The  .•..nditioii  of  the  pulse 
so.in  hecines  p.M.r.  :-..  -oon  that  at  time-  it  may  he  the  iir-t  indieati.Mt 
of  the  iritive  -iixnitican.e  of  alxloininal  ]iaiii  of  sudden  onset,  'I  he 
puKe  li<M.,,m(-  fiv.|U.'nt.  iiTCMular,  and  small  ;  then  thready,  >carccly  to 
he  counted,  and  fiv,|U.ntly,  at  a  tinu'  when  the  patient  i-  still  c.,n-<'i..us 
and  the  friend-  ai.'  -till  hopeful,  is  no  |.,nirer  palpahle  at  the  fa.lial 
artery.  When  peff.,rati..u  with  t;ciicral  pcnt..iiiti-  is  pre-cnt,  the 
hodv-K'mpcitit  ,rc  ri-e<,  .1-  a  ml.',  hut  little,  ill  an  invi-ular  nianucr, 
or  liot  at  all.  ()n!v  toward  the  cn.l  i-  rapi.l  elevation  to  an  extreme 
d.'L'i-ee  -..nictiuie-  ..i.-crv.-d.  M..-t  flv.|Ueutly  a  more  or  le--  rajiid,  often 
ai.rnpt,  decline  of  temperature  t..  far  hcl.,u  the  ii.,r!nal  occurs,  and  per- 
si-t-  until  death.  In  -omc  ca-c-,  c-p,-.  ially  tho-e  with  suhsci|Uent 
elcvafi.m  of  temperature,  I  have  ..h-ervcd  .i  .■hill  at  the  .,ut,-et.  Flow 
thi.-    is    iir"Uirlit    ahout    in    the    in.lividu.il    ease,   ami   which    kind    <if 


sYMIT'iMS   AM)   ciiMrin    l.77o.\X 


2:i:i 


|i.itiiiil-   1  \liiliil    liii.'li,  ;iii«l    wliicli    l(i\v,  tiMi|ii-l'alfiii'-,  1-   li"t    \  il   uIj'uK 


■:ir    111    inr. 


>iil 


111   the  -cvcrot   ca-r-,  tllo^f    in   which   thr  ilitr-linai  cuiilcMlt-,   |«ili|-((l 
■  f    laryi'   ii|iciiinii-,    ^mm   ildtiiic     the   ciiliic   alxluininal    raxitv,    tlic 


II,  urriir   >\iiiiiiiiiiii{i>l\ . 


>\  iii|itniiis  (Ic^ciilpcd,  iiitcii>i(ic(l  tn  ihf  iiiaxiMiiii 
( '■illa|i-c  then  a|>|>rar^  to  <lcV(lo|i  alii'ii|itl\ ,  ihf  |Mil-r  licciiinc>  iMi|Mrr([)- 
lil)lr  iliii-iiiLT  till'  lir-t  ti'W  hours,  ami  tlic  tcinpcratiiic  I'aii^  hriiiw  the 
niiniiai  witli  ri|iial  ra|>iilily.  ()tt<'li  tlic  ahiloiiun  duo  iiut  hi'i'iiiiic 
ili-lriiilnl,  anil  till'  |><Titiiiiitir  pain  i>  ali>cnt,  a  i-irninistanri'  tiiat  ^I'fativ 
inrna-rs  tlic  dilliciilty  uf  dia},Miii.-is  even  tor  tlic  cxjx'i-t  clinician.  The 
iiia|iirity  of  llic-c  jialiciits,  iint'urtunatcly,  retain  pcrtcct  ci>nscii)iisiicss, 
Minic  until  iiiuiicdiatcl\  lict'orc  ilcatli.  wliii 
tcniiiiiatiiiii   lit'  the   tiist    twciitv-t'niir    hmii'- 


niav  lake  place  liet'ol'o  the 


\\  lien   ti m>c  lit'  the  |)erit(iuitis   i-   Icr-^   rapid,  the  patients  may 


even  recnvcr   -nmew 


hat    tViini   tiie   priinai'v   shuck,  tiie   |)nlse   niav 


ram 


lieciiinc   t'uliei-   and    -liiwer,     the    tciiiperatui'e    may    apiin    ris(>,    thniijrh 
lairlv,   it    is   true,  as    has    lieen    mentiuniil,  to   anv    ciin>id 


cralilc   hi  lyht. 


rnfiirtimatcly,  the  hope  thus  amnst'd  is  almost  alwavs  <lcceptive  ;  unlv 

rarely    tluv--   the   |H'rit(initis   Ik me  locally  eireiimserilx'd.      [t  extiMids 

witliuiit  re-lraint,  and  the  local  and  trencral  svmptonis  ii;  icase  aecoril- 
iii^ly,  until  death  occurs  in  ])roliiund  eollapx'  at  the  end  ot'  the  second 
or  the  third  or,  at  the  rurthest,  on  the  t'o'irth  dav.      The  eases  of  severe 


on-ct  ^carcclv  f\tv 


live  lievoud  this  ti 


.More  pnitracicd  cases  may  oeenr  in  which,  in  coiiseqiioncp  nf  the 
form  or  the  Mat  of  the  |M'rfur.itiiin,  as,  for  instance,  when  there  is  a 
sin^dc  or  a  nmiiiier  of  mimite  crihriform  opeiiinirs  close  tofrethor,  minimal 
amounts  (,('  int-tinal  contents  may  slowlv  escajte,  and  temporary  adhe- 
sions   prevent    the   dilViision   ol'  the   iniectiou.-    material    tlirouirhout 


tlie 


entire  iicia 


toneal  cavitv.      !  'ndcr  such 


circumstances,  r.ipid  protrress  and 
com|)lete  cessation  may  a!icrnat<'.  It  is  in  sucli  eas- s,  also,  that,  in 
addition  to  the  jreneral  peritonitis,  one  or  several  partlv  enea])snlate(l 
foci  of  pus  arc  found  in  the  riudit  iliac  fossa,  liehind  the  liver,  in  the 
true  pelvis,  or  in  other  portions  of  the  alidominal  cavity.  Patients  pre- 
sentiiii;  sncli  eonditions  may  live  for  six  or  e-^xlit  days.  I  have  iH'rsiin- 
ally  siHMi  a  frw  cases  in  which  death  occurred  on  the  ninth  or  the  tenth, 
even  on  the  eleventh,  day.  Those  are  horrilile  days  for  friends  and 
Jiliy^iciau,  with  alternation  lietwecn  fear  and  lio|ic,  the  latt<'r  heiti;;:  finallv 
aliiio-t  always  nnredi/cd.  I  cannot  lieliexc  in  spontaiu^ins  n^coverv 
from  universal  perforative  jHritoiiitis,  sueu  as  has  Ix'en  rej)ort<Hl  hy  a 
niimlier  of  ohservcrs.  In  a  numher  of  my  own  cases  t<'rminatinji; 
lavoralily  and  suirjrestin^r  this  po,-si|,ility.  I  would  consider  them  i-atlier 


m 


lAi 


•)• 


■i)i'ii"ii'  1 1  in: 


i;  [ 


IH 


i}W 


ii>  cMMS  nt"  circiiliisiTilicil,  iilthnii^rli  ;it  lim,  -  ,|iiit,.  cMcii-ivr.  |MiMl(initi<- 
ull'ccticiii-,  uliiili  <AliilMl(tl  oiiccial  M'vcritv  nf  tlic  iiiiti:il  >lio(k  mi 
arrciiilit    nf  iinlividihil    cmii-('>. 

:Early  Diagnosis  of  Perforation. — ( '(.ii-iclcrinf.'  tlic  vcrv  jirom- 

i~iiiu    n-nll-   tliMt    li;i\r    liiiii   iilil:ii;ir(l    t'r |Mr:ili\c    iiitcri'rri'iicf    in 

ra-c-  (if  |H  rfoi-itidii,  ami  -inrc  i."""!  i'<~nll-  aiT  tiiaiiilv  <l(|Hii<lcnl  U|".ii 
larK  iTrniiiiitidii  nl'  ilic  ((iiidilioii,  ii  i-  cMrciiuly  (lc~iralili'  lli:il  tin' 
l.liv-ii'ian  -lnnilil  l.ani  1"  ivcnunizc  llir  .-\  iii|it(iiii-  i.l'  /-. -;/m/<//(.,«,  |iar- 
liciilarlv  iif  il-  "ii-ct.  a|iart  tn>m  those  (.f  llic  con-cciitivc  |icrilipnili-. 
Of  all  carlv  -viiiiituiii~.  jiaiii  i-  tlir  iiio-t  coii-tani  ami  iin|HirlaiiI. 
Mi'd-ai' '  ha-  iui>-l  can  tiilly  -Iii<iii<i  the  i|U(-tiiiM  of  alMioiiiiiial  jiain  in 
tvphnid  fiAcr  with  .-|ircial  ivfi  rnu-c  lo  it-  rhafact(  r  in  |>t'rf.ifatiMii. 
I'crfdl-atinii  (iccnrivd  in  \'->  of  hi-  ra-o,  and  in  ail  of  thiin  |>ain  was 
pi-i-i'iit  ami  -ci'imd  -i\(iv.  In  Id  of  ihc-c  ca-c-  tin  patient-  had 
liffii  pf(vion,-l\-  (|iiirt  and  rointiiftalilf.  and  were  -nddcidy  -ci/cil  with 
,-c\tff  aUloiniiial  pain,  which  in  -I  ca.-c>  \\a-  -c\(fc  cnon-h  to  make  the 
jiatient  <'fv  out.  In  tlie  feinainiiifx  •'■  i-a-e-  the  |)ain  wa-  piv-eiit  tof  -onii- 
da\-  hefoiv  the  ]ie1-fol-ation  oi-cin-fed.  In  II  ea-e-  of  -' I  I'epofted  liv 
Shatliiek,  Waiivii,  an<l  (  olili.-  "  there  wa-  carl\  warnint:  pain — earlier 
1)\  a  delinile  iininlier  of  lioin'-  than  the  -cxciv  -\  inptoin-."  it  may  lie 
>aid  that  a  >ndden  oii-et  of  |>ain  deinaml-  the  ino-t  eafefid  exaiiiinatioii 
of  the  patient  and  eaivt'nl  notiiiL^  of  I'Vcry  -y.nptoin.  Altef  oii-et  the 
|iain  i-  n-nallv  not  (dii-tantly  -evdv,  Imt  i>  pafoxy^inal.  in  -onie 
ea-c-  the  pain  may   lie  piv-eiit   for  -evefal    honf-  liefofe  the  oi,-,t  ol'  tcii- 

dei-ne--   ami    nm-clc-pa-ni.       In    many    ca-c-,    howevef,   with    tl n-it 

of  pain  th.'iv  i-  temlerne-,  n-nally  locali/ed.  most  often  -itnated  in  the 
riirht  hvpoi.ra.-trinm.  A— ociated  with  thi-  tt  ndcrncss  thefe  i-  n-nally 
soini  riLMditv  oi-  -|ia-ni  ot' the  ahdoniinal  mn-<-lc-.  c-|ieeially  ot  the  ri^ht 
veetn-,  ami  limitation  of'  the  alxlominal  i'i-pirato|-y  inovemiiit,-.  'i'lic. c 
lat.er  -iun-.  while  not  <v|-taiii.  aiv  ol'th.'  jiivate-t  im|Miilanec  when  taken 
in  c.imiection  with  the  other  -ymiitom-.  A  >nddcn  liill  of  Kody- 
tcinpciatiire,  when  pre-eiit.  i-  a  very  chafac'teri>tie  symptom,  hnt  it- 
frcipiciit  ali-enec.  and  tlu'  fiet  that  it  occnrs  f>-e<|n<'iilly  In  other  condi- 
tion-, -neh  a-  liemorrhan-e,  make  it  an  nnrclialilc  -iirn.  Voinitintr  i-  :in 
important  -vmptom  whrn  pre-ent.  Inerea^inir  di-teiition,  a^  -.lown  hy 
the  u-radnal  ri-e  of  th.'  lower  line  of  hepatic  dnlne-s,  which  -honld  lie 
marked  out  at  short  intervals  in  -iispieions  case-,  is  an  imi"irtant, 
thonLdi  iisnallv  -omcwhal  later,  siirii.  It  mn-t  :il-'>  l"'  r<incml>creil  that 
the  IIi|)poeratic  fai'ics  is  not  only  ,i  late  oeciirreiicc.  hnt  that  the  pinched, 
tlrawii,  anxious   llu'c  may   he  one  of  the  first   siijr^'-estive  si^nis  to  the 

I  /„„..  i-if,  ■'  li,,st,.„   yi..l.  .n„l  Sui-.J.  ./..„,■  ,  .luiii-  i;s.    I'.KMI, 


.SJM//'/o.l/s      I.V/i    ((iMi'l.KWllO.SS. 


235 


(•yiHriiiici'l   (ili-crvcr.      Miuli   attintiiiii  Iims   Ihtii  ^i\in  In  tlic  (|ii 
III  an  iMi'K'  iiicrc'Mx'  in  tlic  iniiulMT  nf  'lie  IrnkcM's  U-  in  tli 


r-lKin 


iIk  r:il 


rtor.itiiiii.      ,\lan\'  more   oii~<r\aIi(in- 


lia\i'  III 


iMilalidii    tiillMwinir    |i( 

lie  niailr  ImIui-c  an  aliMilntcly  acca'atc  olinialion  ut'  iln'  saluc  nl'  llii-  ~i;.rii 


can  lie  ilclciiiiiiin!.       I" 

llial    iiiitiii-aiiiin  <>\    tlii'   IiomI   i>  n.-nall\    ti'liowccl    li\   an    inrna-r  in  llii 


ia\iT     ciinrlnilr*,  tVnni  a  -Inil\   n\'  tlii.~  (jnolinn, 
ti.li, 


nnniiicr  nX    ilic  irnK 


nkiicNic-  in  llic   ucriiiliri'a!   cii'dilaiidii 


•lliis 


niav  III'   riiii~ii 


li'i-alil. 


-iii^lit    ami   a|i|iri'rialili'  unh 


\'    ni   cnni- 


iiansiiii  Willi    |iri'\iiiii.>   rmin 


1^  ;    llcnrc    tllr   ^rral 


ini|MPi'tanrr  ul'  l'rri|iiiiit 
,iliil~  lit'  tllr  li'llkiirvti'-  illllilii;-  tli"  niiT-c  ut'  tllr  ti'MT.  Nut  ilit'lv- 
iiciitl\-,  tiilliiwinii;  the  ri-c  ihnr  i~  a  tiill  ;  ami  in  a  iiniiilici' nf  caM's 
i'i~c   at    all,    lint    tliri'r    nia\   r\rn    In'   a    tall    tVnin    the 


lull'   inav   Ih'   nil 


il.      ( 


iimlltliilis   .-■llrli 


IS    till  -I 


iri'  imiiraliiiii--  nt  the  iiialii:iiit\'  ut    the 


iiiti'iliiiii  iir  till'  |ii'ii-tralii 


II  III    till'  iiaticnt. 


Operative  Treatment. —  Tu  Li  mIih  in  (irmiany  ami  Wil-im  in 


liic   till'  I'l-iilit    111'   tir-l    arili'iitlv    aiKuratiii 


Allli'fira    air    I 

ca-i'- ut' |n  rt'nratix  r  iicriluiiilis.      'I'lic  Aim 


iir   iiiirraliiin    ill 


riraii  -ni'iri-iin>  ourria 


IK   iiiiik 


llii'   -iiliji'i't.  ami    have   li 


-t  i'anu'.-.t   ailviirato  ul'  tlir  utility  ut" 

"  Ilk 


1    was   alilo 


tlii-   |iriiii'iliiri'  ( l'"iiim'y,-  Keen,' Cii.-liinti' ').      I"    \^'M,  Kiti 

t Iliri  I'luiii  till'  liii'i'atiirc  luS  i'a-i"~   ut'  ii|ii'niiiun    t'ur   pcrf'uraiiun    in 

l\|iliiiii|  t'l'M'i'.      Till'  ririi\('r\-rati'   in   llir  riitirr  luScasr--   isi>;',.41   per 


W  liiii   lliis   is  I'lintia^lril    witli    tin'   i 


■i'i'ii\i'rv-i-al('    in    iinujx'r 


itnl 


■a-r-  I  imt  uvrr  .";  pcp  rent. ),  tlu'  valiir  ut'  tin'  |iriiii'iliiri'  i-  I'xiili'iit.      <  )t' 
i|n'rati'il  ii|iiiii  in  tlir  .luliii-.  Hii|ikiiis  IIii-|)ilal  ilnrin^r  tlir    |ia-t 


1  li  ra-r~ 
\\w  VI 'a 
I'liit. 


r-    li\-    l'"inm'V,  ( 'iisliiiiL:,  anil    Miti'hill.  ti    i'itux  crcd- 


■I     lirr 


Tliat  ujirratiuii,  wlirii  |irrturini'il  early,  i's|ieciall\  it'ilmie  nmler  lueal 
I'ueain  aiie^tliesia,  as  aiKueateil  l)v  ('ii-liinu,'  i-  in  it-ilt"  imt  ut'  ^Teat 
ilaiiiTer  III  ihe  |)atii'iit,  i  veil  tliuiiirli  at  the  time  he  i-  extrenu'K'  weak 
Iriim  the  etliels  ut'  the  ili~ease.  lias  liceii  sliuwii  l)v  iinnieruiis  cases,  ami 
e-|ieeially  li--  several  111!  wliiim  ex|iluratui'v  la|iariitumv  was  ilune  ami 
nil  jiertina  m  t'uiinil.  These  results  have  curruliunittKl  the  statement 
ut  Mikiilie/,  niaile  in   ISSl  :    ••  It' su^pieimis  ut'a  pertin-atiun,  uiie  slmiilil 

\ 
imnie<liatelv    |irucee<l   tu   ail 


nut  wait  t'ur  an  exact  <liairmisis  ami  fur  j)eritiinitis  tu  reach  a  ])ruiiunm'e( 


(li'l^ree 


lint. 


nil    tile    ciiiitrarv,   une   sliiilild 


'\|iliiniturv   u|ieratiiin,  which,  in  any  ease,  is  i'ree  frum  daiiLrer."" 

I    have   ulisevved    s|)iiiitaiieuns   ri'cuvcry  i'ruiii  |ierliinitive  ])ei'ituniti.s 


{ 


'./.7i,.v   lf.,p/.i„s   II, .«j,.    Rrp..   V..1.    viii, 
'.A'";-^   Am.    y!,,l.    .I,s.«,„-..  .Tiili.   L>n,    IIIIMI. 


All  III, h  ,if  S. 


./../ill..  nnpi,:,is  II, ..p.  /, 


:/..    Uip 


>].  viii. 


ur,]i'n/.  M-.iVt 


l'l,;i„.  Mill.  ,f,,iir^.  Miinli  :!.   I'.iiMI, 


liuulril  1,\  C'u>liiiii,'.  /'"■.  <■(^ 


ml 


!i!; 


236 


nlllv    111  (•;!>(•>    Ill   w 


ryriimi'  i  ivi'i: 


lii(>)i   >triiiii:   I 


iMtcclnr    :iilhr-|nii^    ;i 


iriniil  ahull 


I      ilic     -ill'    111'     |Ml|il|aIlMl|,     ~t\K 


nil    i'iii'a|i-iil:iti<>M, 
ilnl  llii-  tViiiii  llic  niiiaiiiiii:; 


iru'cr  |M.rli..n  ..|    llic  |K'nl..iii'al 


ar.  Siirli  |iirin-o|'  rilviiiii-cnlM'd  |mii- 
Iniiili-  ina\  al-ii  -■I  in  \i..|,iitly  uitli  jinit'dilinl  niuliiti>laticiM-  ot'  -lh>ik, 
anil,  (-iirciallv  wlnii  laiL^r  Iri'al  alix't— c-  aiT  |irr-(nt.  may  lie  altfinlnl 
williiiiM-t  .^ravr  -yiiiiit.iin-.  li(vii\rr\  mas  iMlnu  umlii-  -ndi  cdiidi- 
tii.i'-  a>  a  iiv~nll  "f  liincly  -nruical  ii!l«T\  cnlii.n,  .t  nf  -|M.nlaiii'(iii-  rn|it- 
iirc  (liiTctK  niii\var<l,  I'l-  inlu  tlir  inlr-linc  nr  nthii'  1  .11. .\\  \  i-cns.  '1  lie 
pi-ii'^iiu-i-  >li(inl(l.  Iiii\\(\cr,  at  Im-1  In-  diiliinn-.  Maii^  I't'  -ndi  ca-c-  dii'. 
In  a  nninluT  ofi-a>c-  I  lia\c  nli-crM'd  <iivnni--ciilicd  |»Titiiiiili« 
(I.Ai  1mi.  with  vci'v  -lii.dil  local  and  ucinTal  ^ym|itiiiii-.  and  |iro;.M-c-r  <|nilc 
s1m\\1\  .  ..Ii.n  wiili  ivniai-Ualily  iittli'  |iain.  and  willi  ivniitli'iil  nrcvcii  iiitcr- 
niittciil  Wwv.  rmltr  -ncli  laiciun-tanrc-  tlir  riinditimi-  |nv-ciit  cuii- 
si-I  |iiinci|iallv  in  -mall  ali-o— .-  .■nia|i-nlat<d  lutwrcii  adliiTcnt  cciils 
(it'  iiit.>tinc,  -itnati  <1,  Ihiwcv.  r.  in  |:ail-  "I'  tli.  alxloiiiinal  cavitv  aci'('->il)l(' 
til    ii|MTativf    intirvintiMii    mily    uilli    ixiirdiiiL'   ditlimlty.      If.    niidcr 


^ll^ll  I'lrriiin-Iann -,  -|Mintaniiin-   iii|i 


tnif  with  riimiilftr  lAarnatinii  dur.' 


not    takr    I 
laliriit    i-    n 


Vr    iilair,    tiii-    iii-lii>-ini:    cnnditioii    may   < 


drair  aloiiir   until    tli 


1 

ini'inh-    of  -nllrriim. 

An    inlfiT-tiiiL'    pi 


lir\.-d  l>\   iliath  due   tu   ^-luiic  t'lirtlicr  ('(iiiiiiiicatiipii,  ur  aiUT 


-itiim    ainiinLr  the  varimi 


fiinns  of  circiiniscrilMHl 


|i('iitoniti-    1-   oriuiiicd     li 


\-    till'    ca-i" 


in    whirh    the    ]iroc(': 


loral- 


i/i-d  to  till-  riirlil  ili;ii-  f"-~:i.  :i'i''  r-|»'i'iiilly  to  tlir  \icinity  ol  the  ciTiim, 
ca-i-  that  ran  l"'  a|ipio|,riatrl\  d.-ii^nati-d  a-  tyjihoid  p(•^itypllliti^  or 
pai'aty|>liliti<.  'I'hi-r  la-i-  oc.-nr  mot'i'  fivipuiitly  than  i-  tri'iKTaily  Ix- 
licvnl,  and  mav  Im'  lookrd  upon  a-  typical  proi-.-M-,  -incr  tlicy  oriyrinate 
from  portions  of  intr-tinr  i-pn'ia 
That 


11\-  involved    ill  i-a-i-  of  typhoid  fever. 


ill    ^neh   ea-i'-    minute   opetiintr-  I'l    | 


f  iiert'oralioii.  or  even   eNtremc 


ileerativ(>   thinnini;   i' 


mav  penmt    the   e-eape  o 

preliensilile  in  aeeordaiiee  with    |irevions    >t;:tei 

to  note   that   the   >ite 


the    inte-tinal    wall    without    actual    perforation, 
f  the    intiamiiiatorv    irritants,    i-   readily   "oni- 


llellts 


It   is   intcrcstinir 


if   the  usual    inn.aniniatioii 


penlyph 


f  the  le-ioiis  in  i|iie-tioii   corresponds  with   that 
,f  the  cecum.       In  the   presence  of  ty]>lioiil 


liti~,  perforation   of  the  vermiform   appendix,  which,  it    i-  W( 

1  ill   the  medullary  iiitiltratioii,  ]ila 


known,  1-  ipiite  trt'iii'i'idly  involvei 
an  impurtant  r^ 


iiood  of  tlie  valve,  as  wi 


T    1 


lavc   in  a  iiiiml)cr  o 


A.       Al<o.  in  the  cecum  it-elf,  e-pecially  in  the  iicii.dil)or- 

it   the  jiiiictioii  with  the  ascending  colon, 

f  iii-tanees  fon.id  deep  ulcers  with  minute   jierfu- 


itions  to  he  the  caii-e  of  circiimsi'r 


ilied    intlammatioiis  in  the  ri'dit 


I    l,.,v-,.  ,,!.-.. 


■  '    tvi.hoid    iHaitvnlllitis  dliriiiL'  all  stair<'s  when  iicri- 


s)Mri<)MS   .I.V/'   <  nMI'I.K    \  I  ln\S. 


'j;$7 


t.iiiiti-  is  likclv  to  <lcv<  l.ip.  with  tinal<  r  r(l;itivc  l'rc(|Uc;i<'y,  ii.iwcviT,  in 
llic  hitir  -liiu't-  "I  I'll'  <li-iM-<'.  anil  r\i  II  iliii-iii'4  cniixalc^i'tiK-t',  in  <inc 
iii-tiiiiv   'ill    llir  cl-lilcciitli,  and  in   aiiuilici-  ..ii    tlir   lucntv-tir-t  alMiiilc 

il-iv.      (  h tl    anil    ( i.in/iiiuicc  '    have  luadi'  similar  (iliscrvation-.      'I'lic 

local  -MHi.loni-  aiv  liUi'  tli.i-r  ol'  i.nlinaiv  inllaniinatory  |ii(i<c>-t~  in  llit- 
iliac  t;,— a,  iiaiiicU,  |(aiiiliil  circiini.~ciil.ctl  iiililtrati<iii,  at  tinic>  nl'  iikkIc- 
ralc  c\tciil,  at  ..tlicr  time-  iikhc  cMcn-ivc,  occa-i.>iially  i(nilc  iniliirat<'il  ; 
tlii-.  it  a|(|>car~  to  inc,  more  readily  aii<l  more  ra]iidly  terminate-  in  an 
ah-ccs-  than  in  ca-cs  otii.'r  than  typhoid.  l'ivci>cly  as  in  thoc  other 
ca-.-s,  the  aU'ection  may  assume  the  chara.'ter-  of  l.oth  perityplilili-  and 
paratvphlitis,  or  ot"  a  comhinatioii  of  l.oth.  In  one  in-taiicc  in  private 
piactici!  I  (.hservcd  the  development  (.f  a  retn. peritoneal  ah^cc-,  which 
w.is  siiceessfiilly  evacuated  thrnn;,di  a  lumbar  incision. 

Tvphoid  perityphlitis  is  not  ahuic  of  thei.relic  inteie-t,  hut  it  is* 
al-i>  a  (M.nditiou  of  practical  imp..rtance.  This  is  true  .-peeiaily  from 
the  diai^nostic  -tandpnint,  and  here,  al.ove  all,  it  is  (.f  importaiur  when 
the  atVection  occuiN  in  association  with  sli-ht,  ill-ch'tined,  at  tiine.s 
protracted  eases  of  typhoid  fovor,  or  in  tliu  course  of  an  att;iek  of 
auil.ulatory   typhoid   fever. 

Tlius,  I  have  observed  I'ases  in  which,  durin'.'  residence  in  the  liospifal 
fi.llowini,'  a  |HTiod  of  ^elle|•al  malai.se  of  tVoiii  twelve  to  titteeii  day.-'  diirati(.ii 
or  loie^iT.  with  irreirular  fever,  unattended  with  diarrliea  an<l  roseohe.  hut 
with  recent  enlarircnieut  of  the  sphvii.  |)erityphlilin  develo|H,'d.  which  then  led 
to  a  correct  interpretation  of  the  condition.  In  (.tlier  eases  that  came  under 
ohservation  with  the  simple  dia'.,'iiosis  of  perityphlitis,  the  history  of  a  L'eneral 
fehrilo  <lisea.se  liaviii;;  pre.'eded  the  local  intlamniatory  process,  and  havim: 
liLsted  sometimes  two  or  three  weeks,  tirst  arouse<l  !.uspi<'ion  of  typhoid  ]>en- 
typhlitis.  which  suhseipieiitly  wa.s  verified  either  hy  the  further  typical  course  of 

the  dlsea.se  or  hv  the urrenee  of  a  (^haraeteristie  relapse.      I  have  ohserved 

eases  of  tvphoid  perityphlitis  in  Herlin  and  in  IfaiiihurL'  in  private  practice 
as  well  a.s  in  hospital  practice.  rnt'ortunately,  no  reference  is  made  to  this 
siil.ject  ill  the  statistics  of  S<'hult/..  Six  of  my  cases  from  the  I>'in<ie  clinic 
arerep<jrted  in  the  dissertation  of  ( ilos  (lM!l-_'i.  Further.  Schoiil.'in  ■  and 
11  ikitanskv  '  mention  the  .■iMiditiou  in  <piestion.  (^Jrie-siiiL'er  and  Chvostek 
alsi.  were  awtire  of  its  occurrence.  Recently,  it  has  l«-en  mentioned  in  the 
dis.sertations  of  I,;ini,'held.  Sehneller.  and  llol.'cher.*  Cases  of  typhoid  peri- 
typhlitis, such  as  have  heen  descrihcd  hy  Hesnier  and  Follet,  l.eloiiir  in  this 
eateirorv  svmptoiuaticallv.  Imt  not  etioloL'ically.  These  were  cases  of  ordi- 
nary peritvphlitis  pursuiiiL'-  a  septic  course,  they  are  capahle,  it  is  true,  of 
causim,'  irreat  ditHcultv  in  diH'erential  diatrnosis.  Thus,  T  can  recall  a  case 
under  mv  oliservation  in  which.  durinL' the  course  of  the  disease,  intercurrent 
imilaleral  jiarotitis  ai)peared  to  he  especially  indicative  of  tvphoid  fever.  It 
suli.secpientlv  proved  to  he  a  .septic  metaj^tasis  from"  a  purulent  focus  m  the 
iliac  fossa. 


1   T/i'^r,  Tan-.  1«SI. 

3  I.rlii-linch  ilrr  p'lf/ifU'fjisrhen  Atintfrniie. 


2  !\lin.    V'.rlfiiinu:ryi 
*  //0I-.   cit. 


m 


iM 


I 


2:w 


rvrii"!!'  1 1  VI  I! 


iiii|iar;itiv(lv 


liltl 


iMiriiiiii:  till'  I'.i-i'-    111    |"riloiiili- 


■liiiii  uiih  iuli.iiiiiiiiilii'ii.  -I'lhiniiL:,  ;inil  ni|iiiiir  mI  ulln  r  mIhIhiii- 


lo     ulli.ll 


Mi-i'l<  r;ilii>ii    li.i-    ;i 


In-M.U 


ri    ijiMii. 


|p.ii-|iriil;irl\     lliii-c    i\n<-    111    iii|iliiiv   ..!'   till-    -|ili(n    .incl    llir    iin-iiitcrii' 
:i'      c-i-aiic   iiiiircl    cliniral    iiiln  |ii  i  lal  ii  .11.        I'lic    ran' 


ami-.  aliiH'-l  alw 


in-laiir(  - 


.r   |iii-|'.iraii.iii    .,1    il 


lal-r    liili 


lai'v  |ia--a''-i  - 


i|-   111'  -(■(■uiiilarv 


aii-io-   I 


i|'  thr    li\ir   can    ^ciicrally    mily    lie    -ii-|ici'li  i 


1   '  1 


'.^KSi 


ALTERATIONS    IN    THE    RESPIRATORY    ORGANS. 

'I'lic-f  arr  aiiioiiL:  tin'  t  lV(i|iirni  ami  ihr  imi-l  \aiiiil  ili-nnlrr-  in 

the  i'iilir-c  111'   Ivhlii'i'l   U\rv.       '\'\\i\    cciii-i-i   ill   iiart    .il'aclnal    ci  iliiplica- 


ilir    alli 


IMlrllt      lllHill     t 


li,,ii-  ami  ~ii|m'-,  111  |iarl  nl  -Mriaiir  aucaai  a  m-  n 
liac'illu-  111'  I'.liri'tli  ami  il-  |iniclml-.  A  -liarji  ililli  rent  iatimi  lutwicii 
ilir  iwii  -rl-  111'  riiiiililii'ii-  i-  mil.  a-  \(l,  |io--iiilr  ;  il  i-,  ImwiAi  r,  |irii|i- 
jiil,  lliat  till'  r\lrii-i\i  calarrhal  ami  iiitaili  iiillaiiinialnrx  all('ralii'ii> 
in  llir  i-i-|>ii-aliir\  iiri^aii-  i-|Hi'iall_\  lirlmi^^  iliuli  i^ii-ally  in  llic  xthikI 
(■al('jiir\  . 

Alterations  in  the  Nose  and  the  Nasopharynx       ili.  mi-c 

aiiil  llir  na-iiiiliar\  n\  iiiiili'  ijtnrrailx  cxliiliil  at  tlic  lir;:iiiniii'.  ami  at 
ihc  lui-iit  111'  tlir  ili-ca-r  till'  rnmliliiiii  111'  -I'-rallnl  ilfv  catarrli.  'I'lii' 
iiiiii'i.ii-  Mimiliranr  nl'  tin-  iiom'  i-  liki'ly  In  lir  irililciinl  ami  -|ionj;y,  ami 
il  ri(i|miitl\  I'Nhiliii-  a  ilark-rcil.  M'Uity  -wdlinir,  r-|M'i-ially  nvir  tlii' 
tniliinati'il  liiiiic.  Tin'  M-cntinn  1-.  iimlcr  -nrli  comlitinn-.  i|iiit('  inml- 
ci-ati',  :iml  tlic  iirilii'i'  ami  antrrinr  |>iiiliiiii  nl'  tlic  iia-al  ravity  arc  dftcii 
ciivcnil  witii  a  fnliciiinn-  ilc|iu>it.  1 1'  llic  naMil  easily  Kc  vci-y  narmw 
nminallv  nr  in  ciin-ccini'nn'  ul'  roTiL'ciiital  i<v  an|uiri'il  cliaiitri'  in  .-liapc, 
it-  pcrincaMlity  mav  he  irnatly  (liiniiii>li('<l,  w  iili  ri'-iiltinL'  |iatliiilni:ic 
ninntli-lii-i'atliiiiL',  the  con^ciiiiciH'cs  nt'  which  aro  duiilily  injmioiis  to  tin- 

tV|)llni(l     ]lMticllt. 

Fi'i.Tii  the  -vni|iliiiiialiiliit:ic  slaml|>iiinl,  it  inii>t  he  cin|iha>iz("il  ttiat 
the  oi'dinarv  <vm|.t.ini-  ul'  cury/a — -ncc/iiiL',  iiicrcaM'il  -ccrctioii.  cmi- 
innctivat  catan-h — arc  ainuiic-  the  ;.rrcatc-t  c\cc|ition^,  at  Ica-t  in 
imiilci-atclv  -cvcrc  ami  -cvcrc  <'asc<  ut'  tyjilmiil  li'vcr,  ami  .nay  he 
thri.wii  in  the  halancc  air;iin-l  a  iliairn"<i<  ><\'  typlmid  U'vcr.  S'vcrc 
inl'ci'tioii-  c.imlition-  with  a  i)rc<liiniinatin;r  cnry/a  L'i'ncrally  have  some 
other  -iLniilicancc.  I'mlcr  such  cirenni<tan('c-.  ty|>hns  fever  and  inliil- 
ciiza  es|,|.ciallv  wimld  have  to  lie  ciin<idcre(i. 

The  hvperemia   not    rarely  hccoiiic-  -o  marked    that  even  mi   merely 

Mowiiie-    the    mi-e    hi Iv    niiicii-   i-  ili-chanred,  or  -mall    amount,-  of 

Mood  L';iin  entrance  into  the  na-o|>haryn\-,  which,  when  expelled  in  the 
form  of  -anL'^niiiolcnt  -])nlnni,  may  irive  ri-e  to  niinccessary  alarm,     (inite 


Mi//'/'*i/s-  AMI  I  <iMi':  If  \ri'iy'<. 

fi.  c|ii.iillv  till'  t'i;iv'ilit\  (it  llii'  liliM.i|-\i--(U  lit  tlir  ii;i>m1  miirmi-  imrii 


•J.'.O 


1^  -u  liiall\i-<l 


lli;it  ;ii  IumI  |iriitii-c  t|ii- 


l:i\l>  iiciiii- 


11 


ll~    I-   iill-CIVill    llV 


tiir  llir  iiiiiir  ticijuiiills  (liiiiii;^  the  |i<iiiii|  uf  iiiciilKil imi  ami  in  tlic 
Iwiriiiiiiiit;  lit'  till  tiliiilc  -lM;fr.  I  licliiAc  llial  M I  |ii  r  iiiit.  nt'  all  i-a>cs 
■  it  i|ii-ta\i-  liiiriiiL'^  l\|iliiilil  tis  rr  uciiii' at  llii-  liim.      Nn-i -Miiil  i-  li-^ 


iillrli;  at  till'  l)i';.'illllill;_'  ut   ihf  -(iiitlil  Ur< 


k,  u  liili'  it  i^  iiiiciiiiuiiiiii  at  till' 


u\ii\]t  1)1"  till'  ili-ca-r,  liiTnMiiliu'  a^'aili  -miirwliat  ninri-  t'n-i|Mriit  ililliiii;  the 
a-I  ilay-  uf  the  ti\ri-,  in  l\,r  |m'I  iml  ut'  -trc|i  rlirvr-,  ami  (lmill;_'  niiivalc— 
•iiiii'.  lUccdiiii,'  t'l'irii  liii'  iiu-c  may  lie  ii|irati<l  >(Vtral  tiiiio  within 
I    -hurt  ]»riiMl,  ami    it    may  iK-ca-iuiially  !»•   -u    |ii(itii-c  that,  in  -|iitf  >>i' 

ijiliiin   ut'  the   |>aliiiil    at    lii-l.  it    may 
I  a  lali'  iK'i-iuil  in  tln'  tilifili' 


ii'riit    ariirliuialiun    uf  tl 


a|i|> 

i:ri'atl\'  (lr|irc--  l!mi  ;   ami  wlirn    it    ucciii-   at  a 

-tai^i'  u|-  iliiiin;^  runvalc-i-cm-r,  ii    mav    In-  ilircctly 


a    -onrcc   ul    ihinp 


ii 


II  a  mmiliiT  ut  ui^laiirt'w  I  liavi'  uliscrvcil  jialiciil.-  iiinlfr  siicli  (•omliliciii.s 


rriliirt'il  to  an  alaniiiiu 
ua.-  cuiiiiicllcii  to  nsorl  to 


folate  of  ilchililv.      1 1 


!('  rase  III  jirivalc   prai 


ti.r   1 


siil)ciilaiu"oiis  iiifii>ioii  ot'  iilooil,  anil  in  aiiotliif  lo 
il  roihicc  saline  infusion  liciicatli  the  skin,  in  onliT  lo  overcome  the  iniiiemliii;,' 


ilaiiL'er.      laelHTineisler  has  oliserved  '1  fatal 


anil  Mriini|)e 


II  1.      T: 


|ioiiaile  of  the  ni 
rarely  nccessarv. 


■veil  from    hehiinl  s\itli  IJell |'s  eaniuihi,  is  not   at  all 


It    niav  lie   mentiuniil  t'nrllicr  that    iiu-i-lih  id  iilav-  a  nut  ii 


fant  n'l/i  in  tl 


le  oaM's  1 


•t'  liiinurihao-ie  ty|>hiiiil    ti\ri-,  '.vliirli,  tiirtiiiiatrl\ 


•nr  hilt  ranlv,  and  arc  atlcndcd  with  sii 


ch  a  ).n'avc  jirui^nu-is.      Ajiart 


fruni  tiicM'  licmuriliai:i<-  cases,  which    nia\'  ucciir  at  ai 


ly  ao^c,  vunn^r  pcr- 


Miiis  arc  pai'tiinlarK  likdv  tn  he  altacked  with  nusc-hlced  ;  cliililren 
under  tlie  aire  ut'  ten  years  le.->  eunmiunly,  it  is  true,  tiian  older  ones. 
Kpistaxis,  in  my  e.\|>erienee,  rarely  ueeiirs  after  the  furticth  ur  furtv-fiftli 


d  it  till 


year,  ami  it  then  uceiir-  alinust  s,ii,.|y  m  persniis  prcseiitintr  other  ttre- 
ili-|iii»iiiir  eundiliiiiis,  either  local  ur  ircneral,  as,  fur  instance,  elinmic 
ah'uhuli^m.  N\  ith  icfxanl  tu  the  frei|iieiicy  of  epistaxis  in  iretieral,  it 
may  Ix'  state<l  that  I  have  oliserved  it  in  t!.')  |K'r  cent,  of  17(»l  eases 
investiiratetl  as  tu  this  |>uiiil — a  prupurtioii  that  api)ruxiiiiatis  that  fuiiiid 
by  FiielH'rnicist<'r  (7.")  per  cent.). 

Cruiipous  and  diphtheric  aHeetiuns  (<{"  the  nasal  inneuus  niotnbrane, 
which  are  rather  trc(|iiently  mentioned  in  ulder  writinir-,  I  have  observed 
with  extreme  rarity  in  cases  of  typlmid  fever.  When  ]irescnt  nt  all. 
they  iweurred  alniust  exclusively  in  n^^sociatiun  with  similar  ])n)ce>ses 
in  the  pharynx  and  n|m!i  the  tonsils,  in  which  they  likewise  occur  but 
exeeptionally. 

Larynx,    Trachea,   and    Bronchi If   thise    stnicturos  ,4' 

patients  with   typhoid   fever  are   freijuently  exaniiued,  some  spon^incss 


J      111 


I 


mi  -ff^: 


/  )  rii'iih  1 1  \  /:i; 


Miiil    ii  ilri(  -- 


.1    till'    I 


inn  I  III-    iiic mill  ,1111    w  II 


.1      III!       I.ll-r 


iimI     r:iri'l\    III'    liiiiinl    in    tl 

I, 


nii|~  ainl     llii'    ars  I I'l  r.ii't  ila^'i-,   iirip|>alil\ 


al-ii  -li;^lil  ili-i'.i|i'laU'iii  ,.|  llir  Inn  \i,ral  ImimI-,  i-|.(rlall\  at  llirir 
iM.iiil-  n\  allarliiiiiiil,  ami  lalliir  al  tin  |"i-li  ii.ir  liiaii  al  lln  aiili  lioi- 
ii,, 111. 111.  'Ilir  lai'v  Ml:' al  iiiiirnu-  iiiiiiilirain  al-.i  |rii-riii-  an  a|p|Maranii 
(iT  ilr\  II"--.      I  lir  Mill  <    "I  till'  |i:iliiiil   niiil.  1-  -inli  rniiiiii-lani  i-  i-  wiak, 


iiiici  I'tain,  .,iiii -iiini  u  lial   li-iai-r 


M. 


inniiiiiniriil  ralanlial  laiv  iiiiili- 


witli  I -|ii  c  lalU    iiiaiivi'i  -\  iii|>lii|ii-   I-,  III!  till 

la' I,    it    I-    aliii'i-l    a-     ran     a-     niarUiil     ri.i'\/a. 


■  riliar\  .   iinl    tV('i|iii'ii!  — in 
"In-    nin-l    a:jaiu    lir 


i|ilia-i/iil    in    rontia-I    uilli    I\|ilin-    livn',   in    tlic   iliai.'ii"-i-   "t    w  liii'li 


il    ami 


ar\  ni;i'ai    ralaiiii    i-    p'lnialK     i.l    iin|"irlaiii 


<  »|    ._;i'ial    iniiiiiilaiii    .••ii   tin-   ■.ihrr    liainl,   in    ••■.>- 


'I 
art'    nmrr    |ii'nliiuiiii    all  i  linii-  nl'  t 
iiii-inliranc,  ami    |iiiirliiimlrili-.       I  I 


'I'  i\ iiimiii  i; 


111'    lai  \  n\,    nil  riali'iii    "t    tin'    nnn  oil- 


II    111  null  111 


il,  tciini.  ami   ii'iir-f 


il    till 


-I'    n  iliilil  loll-    al 


I  \  jural    llial    till     iiiii'-li..ii    ai  i-i 


All'    Il 


III. Ill     tl.i'     i'liii|iii;i 


ir     -Iaml|i..iiil.    a     pari     nl     lln'    l\ 


.ill    I'.'M'i'    ii-.ir 


.\llli"iii;li  little  i-  a-  vil  known  in  llii-  ronni.-'l  ion  iVoin  llir  l.arti  rio- 
lo'^ii-  -tanil|ioiiil,  all  allii  mat  i\  .■  lomln-i.  .n  willi  rri:aril  to-..inrot'  ihc 
alli'i'alion-  i-  iiii.-l  |ir..lialiii  t'.'ia  nnnilni'  ol  ri'a-.iii-.  A-  i-  Km.wri, 
1 1  nil'  liaM'  I II  I  II  iliinon-iiali  il  (<  oi  nil  ami  Uaiu  iii.  ami  otlirr-  )  in  ra-rs 
ot'  l\|ilioiil  li\i'r,  n|i..li  llir  |io-lrii..|'  wall  ..T  llir  lai'NIlX,  lirtwcili  tlic 
iioiiil-  of  attai'lnm  111   of  ihr  \-.  ical   lialiil-.  in   tin     \  iiiiiilyof  tlif  ar\  tilioiil 


i-artilaui' 


ami    inioii    t 


111'   I'liiL'lotli 


I-.    r-l>('i'iall\     a 


t    it-    lia-c,    lnrinatioii- 


■li  an-  to  III'  lo..ki'i|  ii|ioii  a-  ri'iTiilly  inlillratiil  ly ni|ili-t'olli('li-, 
paralilr  with  -iiiiilar  li-ioii-  in  tlir  inti-l.m'  ami  in  otlnr  ii.irli.iii-  nl' 
lioilv.      A-  |,r('\ion-l\    m. mi.. m.l  i -rr  -ntion  on   l'atlioln;:y  ),  Si'lniltz 


has  h, 


I 
I.l  ili'inoii-tratf  tin'    'vph' 


Hl-harllll    ill 


thi-r   I'ollirli-   ill   ill 


I.iki'   thr    ti.llii'li-   in    till-   inti-ti 


'\lillilt     .1     liial 


kill 


t-mli'iirv    to   nmii'i-ij-o   nccrnlir  ilr-tnnli 
alliirili'il  for  thi'  ilrvrluii 


Thr     I 


rnaiincr.  an 

(liriilnl.         It 

atVfcti 


11,   -o  lliat     tlnrcliy    a    liirall-    is 

II'--  ilirp  ami  i'\ti'n-i\'r  illi'cl,-. 

if  till    lar\  n\    t.iki-  |ilari'   in  thi- 

I   iiMW  iiftiii   It    i-  ihli'  to  olhiT  caii-i*-.  ran  at   |iri'-inl    Hot    li(> 


ri'inirnrv  w  i 


iiictit  ot    iiiorr  or 


til  whii-ii    nlri'i'Mti 


1-  ciTtain,  liowi'V  r 


tli't  llii 


iht 


ilithi'iir  a 


ml    |i-rniloili|i|iilit'ru' 


Iticrtlnn-.   wlilrli 


ittrii   wiiT   liilil    i-i-]ion-ilii      liy  carliir   wiiiir-,    have 


■tnliiallv    Ihtoiiic    lr-<    fVi'i|n.  iitly    a 


■aii-i'   ol    till-    roinlilioii. 


^iiiitlicr    inoijr 


.1'  oriirin    for    nli'rration 


ipprars    ijiii 


tr    fmini'tit.      Tl 


if    till'     lar\ii\,    Il 
Its    fr 


II'    ilitmn    thru    iv-iilts    tnnii    -ma 


at 


first  -liallow.  Ii--iiri's  am!  cro-ions  iiivoii  the  postcro-intcrii 


ll  wall  of  thr 


larynv,  liitwicn    tin 

l^f  tlip  vocal    liaml-.  wliii 


/ti'iioiii    rartihiL'f^   :imi  tin'  point-  of  attai-liimiit 


■h    1.- 


loll-,    olivilill-lv,    lit 


vclop  as  II  con-i'ijncm'c 


of  the  I 


i\|ii'i'i'iiiia  ai 


il  ilrviicss  of  the  inuniii-  mciiibr.i 


brani'  and  the  iiiclvastHl 


N  )    1//7'/  1/v      I  \/,    I  o  1//7  /<    I  I  /<,\S. 


2\\ 


ri-|iiiMl'pi\  .iili\  il\  ami  liiiiiii  nl  c-.iii:.'li. 


W 


ri  -ii'li   -inall   ti--iiii-  .iiii 


illi>  li.il    1  \''c.iiali'pii-    Iia\i    oiiir    ill  \i  loiiiil,   llii-  iii'uci--,  i.uiii_'    |i.  ill) 


li  iii|i  II'  ■>    I'p  I  i--iii-<li  •_•'  III  ralMii  al  iIh    Ii 


[■■111  1. 1   -lAi  it  atl. 


IrVii',    iraili        I  \liii 


I   .    ami    il     niila\  iii'aliK     -iliialiil    ami 


>r  IV  iiliiMil 


ariiiiii|i:iiiii-i 


itiliri-    ii.in|iliialiiiir    I'liinliliMU-,    attain-    a    roii-iili  laMi     i|i  |itli. 

I'll. til    till     lllii  I-    rr-llllilli;   lliilll    tlir   Ilcrrii-i-  of  liillu'lr-.    llnl    tim-i'  clllf 


til   ti--iiir-   ami   I'fi  i-ii>ii-.  iiia\    iiiMiUc   an 


I    iH-mtiali     ll 


11     iini  'oil-  niciii- 


liiam-    111    a    vars  iii'_'    iMiiit. 


W  I 


II  11     ll|i\      lll\<i|Si'    II-    .lltirr    tllliklli-^ 


■liiiiiijriti-  uiili   |Miirli'imliilii-    ali-rr--i -.  al 

II 


i|  i\  III    r  itliir  1  All 


II,  riii-i-  .it  .■artila'_"'.  \\  it li  rm  ri-|>iiiiiliiiL: i\    -i  \  ■  n  .  ilaimi  imi-.  ami,  iiinli'f 

lllr    Mlii-t    l;l\ 'ilalilr  rilrlllll-tallii-,   |iliitlaitiil    -ii|i|il-.    Illa\     I'l-lllt. 

W'l,  tliiT  -iiiji  ili-i|i  iilii-r-  i-aii.  jiv  ri-a-iiii  ut'  tin  ir  incnic'  n|'  nnL'iti.  Ik' 
ilcsiiriiMli'ii  .Iciailiiial  iii  lln'  -irul  si'U-i-  |)illnrli  :>!•  Iia>  lniu  ilmic  l.v 
carliiT  writer-  ilni',-  iimI  M|i]ii  ar  !'•  Im- ilrtiniti'lv  ilitrriiiiiii'il.  I  lulicvr  tlial 
al  the  |iri'.-i  lit  ila\  a  inrrirt  iipiiii|iiiiiii  rauiint  In-  iMrimii  ul'  llic  iiifcliaiii.-m 
liv  uliiili  -ii'li  ulrcratimi  i.-  Iirua.'lil  almui. 


'I'lir  -I'at  lit' till-  I'lyii^'ral   iiln'raliuM  i-  n  ni-taiit.  aliiin-t   tv[iiral.        \- 


a-    liri-ii    imiitiiiiiiil.   It   I-   imi-l    lrriiiiri:tl\    -itiiati'd    uiium    t' 


|MI-tl-fll 


Wall  111'  till-  lar\  ii\,  lAlrinlia'j-  at   tiiiir-  tn  lIn'  rmit  lui.nii-  |iii|-tii  i|i-  nt'  tlr 


ittailiiiii  lit-  111'  till'  \nial   liai    I-.  in   tin-  I: 


ilti  r  -iiiiatiiiii.  It  1-  Iriic,  alnm^t 


-iilily  ill  the  rm-iii  nt'  -liirlit  i  I'l-inii-.       W'itli  tlii-  -rat  nl'  |iifililcrtiiin  tiir 
llir    iiln  ratinii    i-   a--iiiiali-il    tlir   l-ii-t    tliat    -ii-i  iinlarv  |Mriihiiiiilrili-   ami 


i-i-    111'  till-   i-ai-lila:;v    iiivnlvi-    in    ll 


iiajiiritv  111'  i-a-r-   llic   rrirnid 


ami    af\tc  inml   raftilaurr-. 
iilliri'  -itnaliiiii-    in    I  lir    in 


y|iliiiii|    iilrir-    a|i|iiar  tn   lie   i|iiilf    i-arc   at 


liiinr  111'  till-    larynx.       I    liavc  in  mir  in-lain'i' 
rrvcil.  in  a--iii'iatiiiii  uitli  iilcriatiuii   ii|iiiii  tin-  jm-li  lim-  wall,  cfii-iipii 


III'  the  ll  It   Miiti'iiailar  liam!, 

I  Icri'ati'iii  uiTiir-  lint  niiii'li  Ir--  I'liniinnnlv  iipnn  tlir  ipitrluttis  tli; 
it  line-  ii|iiiii  till'  |iii-trriiii'  wall,  liiil  in  i:iaii'ral  it  i-  tlii-rc  iniuli  li--  ijr 
ami  Ir--  r\tfii<ivc.      I'lulrr  -iirli  rifiiiiii-taiirr-   larviiL'! i-<'<i|ii('  cxainin 


tiiin    iil'tin    lii-ciuMS    niiiiirfiiii-    -mall    -lialli 


the  inarL;in    i<'  tin'  riiitrlnt 


ti-.       I   havi'  I'l 


\v,  ra ^'l;') ■! I ,  iilciT-  iii'i'iiiiviiii^ 


i|nrntl\'  iili-iTVrd  tlii'in  in 


(■iatinii  with    tolliriilar   -VM'lliiiL''  ami    nlriTatinii    in  llir  thruat. 


r-liri-l;lllv 


with  tlir  iiiTiiliar  I'fii-ivi'  iiillaiiiniatiuii  nt' the  -nt'l  |ialatr;m(l  tlir  tmi-ils 
|iiTviiiii-ly  nii'iitium-il.  linitr  ciiiiiimniU  tlir  nlrrr-  rxtriid  dipwii  tn  the 
rai'tilairr  and  raii-r  rxfuliatiiiM  nt"  -mall  ]iiirtiiiii-,  ( )iilv  r\rr|iliiiiiallv 
diir-  rxtcii-ivr  nrrnxi-  nf  the  r|iii_r|ntti-  take  |ila('(',  Iraviiiir  hlf^rr  drt'rcts. 
F,-|)r<ially  MVrrr  ra-rs  of  thi-  kind  liavr  hrcn  rrrurdrd  in  fhr  litrratiirc 


-I 
li\-    MiHirr,-   Wr-t,''  and   ntllrr.-.        I    li; 


ia\r  |irr-iiiial!v  iihsrrvrd  at    aiitii|i-v 


16 


)/>«.  Vii'iirui.  I'<'>n. 


pp   L'.-.;i.  L'OO. 


TYI'll'ill)   Fl'VFIl 


ill  one  iii>t;ilii'<'  (Ic^ti'iictimi  nt'  niic-tiiiiil  ot'  the  ciiiMlnlti-  liv  ncf'nwl^, 
.•mil  ill  MiHitlici-  iii>l:iiiii-  iiciru^i-;  ot' iiinrc  tliMii  liiilt'.  Nixcrtli'^lc--,  \\\y.\y\ 
f'nuii  tlicsf  cxtcii^ivc  loioii-,  atVcctinn*  of  ihc  cpiu^lcitlis  ;ii'c  liv  nn  iikmiw 


ihiiiLT"  ri>u-  ;i>  llii)>c  nt'ilic  inliiicii-  nt'llic  Imi'siix.      '11 


irv  Ml'c  nttcli   liiil 


III'    Mllprri-Kltlli 


hll 


even    Iliitlrril     liy   tlir    ~l  ll|ii  Hi  ills    ]iMtirlll.  ami    iit'till     lirrm 

niil\    lliriiiij.'-li  (litliciillv  ill  >\v:illii\viiii:-.      (  liilv  in  r:i-i-  in  wliii-ji  tliccmi- 

^titiitiiiiial   I litimi    is   i_'i':i\r,  m'  wlirn-  \vr\  ixliii-;    . dflrrts   oxist  in 

tlu'  cpiirliittis,  dm-  aspiratii m- |iiiiiiiiiiiiiia  ili\rlii|i. 

riic  iiiiirli  iiiiiic  l'n'i|iiiiit  |)riil'niiiiil  lii-liirliancis  due  to  ulceration 
oC  till'  intii'iiir  ot"  tiir  larynx  air  nt'  \ari(il  kiiiil.  IJctorc  the  nlcci'alivc 
]il'iM-(>-  rvtrml-  ilnyly  —  nmn-  t'iii|iiriit jy ,  inilinl,  it'  tlii>  i>  tile  I'a-i' — 
filriiia  lit'  till'  L^otlis  may  ilr\ri<p|i.  At  liiiir-  it  a|i|iiar-  i|iiilr  iiiicx- 
piTtrilly,  anil  then  iiuTea^rs  wiili  siirli  rapiiliix  tliat  even  in  lios|)itals 
suH'ocaliiiii    lias  orciirrril    liil'mr   liaclnnloiin-    rmilil    lie   |)crtiiriiicil. 

A  fiirtlicf  -crioii-  ilaiii^cr  rr-iiir-  in  iIh^  )iii--ilili'  (Irx'cloiinirnt  of 
]«i'irlinniliilir  ali-ii--  ami  n  ■ro-i-  of  rarliiai:i'-  Tin'  cricoid  rartila::'!', 
uliicli  is  nio-t  fri'i|iiriiily  iiiMPiMil.  may  !"•  ilc-trnvrd  tlifoiiiilioiit  aliiio-t 
it~  entire  lAtcit.  Next  In  it  in  tVei|iirnry  thr  ai'\leiioiil  eartilai;-e-  are 
involved,  and  are  frei|iuiilly  liatlied  in  pii-  and  partiall\- or  wliollv  extii- 
lialed.  In  one  iii-tanee  I  oli-erved  expectoration  of  an  entire  arvteiioid 
<-artilaire  ;  tlii-    maetimi-  oiTiir-   aUo    in   ca-i-  of  typliii-   I'ex'er.      'i'liat 

snrli    perieliondritic    pi --es   are    mmi'    likelv    than    ~imple    iilcei-    to 

caii-c  marked  tiiniet'aciioii  ot'  ihr  minoii-  niciiilirane  and  stenotic  edema 
ot'  the  larvnx  i-  oliviou-.  If.  ImwcMr.  in  siicli  ca»e~  the  impendiiiir 
danger  to  lit'e  is  avrrlid  liy  trachcotumy ,  the  patient*  are  -till  exposed 
to  ihr  nio-i  -crioiis  ciin--ei|iieiiee-  iliie  tn  cxtcn-i\e  iilcrrat ion  and  corre- 
s|ionilin'j:  lo-s  of  cartilage  The  sli^hte-t  nt'thc-e  di-tiirliaiices  con-i-ts 
III  the  ncci--ity  of  wcariiiu''  a  canmila  tiir  a  eoii-idcralilc  leiii^th  ot'  time, 
and  the  pcr-i-tiiicc  liir  a  further  period  nf  a  certain  iIil;iii' of  hoar-c- 
iic--.  When  -r\rrc  ricatriiTal  stenosi-  of  the  lar\iix  dixrlnp-.  -onie 
patients  mn~I  ennliniie  to  wear  .1  eanmila  pi  rmaneiith  :  or  in  t'aNnralile 
ea-e-  -lime  deirree  nl'  impro\enient  ma\  he  -eeiired  li\  Iniiu  coiir-e-  ii|' 
dilatation  with    lioii^iie-. 

Fiirtiin.ately,  -eeomlarv  -iippiiratioii  and  Liani^i'i  ne  in  the  cellular 
ti--iie-  ot'  the  neek  aiiil  it-  viei:iitv  are  •are  in  eoimeetion  with  -iippii- 
rative  perichmidriti-.  In  one  iii-iancc  I  oii-er\ed  piiiiilint  ]io-teriiir 
iiiedia-tiiiiti-.  .iiid  in  a  tiiimliei  nl'  in-t.iiiee-  lnirniw  iiie  of  the  jm-  into 
the  anterior  ncilia-timim.  <^iiile  exeeptioiialK'  (Wiikei.  exten-i\c 
ciit.aniiiiis  emphv-ema.  invnlvini:  the  lari^-er  jiortion  of  the  lioih.  ha- 
lieen  de-evilied    in    the   -ei|nence  of  perforiitimi    ot    the  tlivroid  cartil,aL''e. 

\\  heiher  t\  |)lioiil  perichondritis  may  diAclop  diieelh   .iiid   indepeiid- 


SYMi'Toys  .\M>  cnyii'i.Kwrioss. 


1A,\ 


itlv   witliuiit  antfccdciit   iilccrutiim    i>t'   tlic  niiicinis   mciTihninc,  ;is    is 


l(ch<-vt'(l   l>v 


Ditt 


i-icli   ;iiiii  citlicrs,  IS  :is   vt 


t  mMl(i!iuiistr:!!<il.  Hut  with 
(iiir  recent  kii('\\le<li.'-e  wilii  reunnl  to  typhoid  ostemnyelitis  and  ]KTi- 
(i-titis,  tile  i|iie>ti<in  can  l)y  no  means  l)e  i^^nmed.  I  liave  |)ei-siinally 
eneiiiintered  a  ea-e  in  whicli,  on  earetiil  iarynjriiM'i'pie  ex-niination,  tlie 
arvtemiid  eaitiiaue-,  liie  e|iii;l(itti-.  and  tlie  entire  interim-  nf  the  hirynx 


Were  t'dund  I'lear,  \\U\ 


\v  eiicinnMTilied  intlannnatinn  of  the  tiivroid    ear- 


tilau'i',  attended  iVdni  tiie  outlet  with  ~\veiiinL;-  (it'tiie  antei'iitr  ]iiii'tiiin  nt 
tlie    rieek,   developed.       There    re-nlted    siiniinratii 


lunuwinii;   ot'    the 


]ins  ix'tween  tlie  ( 
.it'    eartilairi'   alioii 


leep  nin~eles  of  the  neek,  and  extliljation  of  a  portion 
I     (h 


iiiai'ter- 


an    inrh    in    ihainetei', 


linallv    liv  nneoinplie 


ited 


verv  without    ~ti'iio^is  or   nnpairnient 


tlie  voiei 


On   t 


n    the    wliole 


the    thvroK 


I    eartilaire 


'p: 


•ars   to  1)0  1)V  tar 


tlie   least    fre(pieiilly    involved   of  all. 


Tl 


ic    'Heraliiri'  cDiitaiMs  a    larire   iiuiiioer   n 


tviilioid  iieerDsis  of  the  lurviix. 


Ext 


eiisivc    II 


f  isolatecl    eases  of  oxteiL-^ive 
iiecrn.-is   lit'  entire   eartihiLres  or 


irtions  of   curlihiire    have    In 


ot     iiidivichial 

DeHroeii,'  (Jill'iard.'  S'kretaii.'  Diltlieil,    and  oil 


a     recnniei 


IV    I  acliiiiaver. 


A  <()lle<'tive  report  of 


the  eases  of  severe  tvphi'iii  iiiv 


;Kenieiit    of  the  larviix   i '_'00  cases  I.  toiretlier 


ith  14 


lersonal  cases,  h.as    lieen 


iii;ale    hv  1 


uiiiiiLr. 


lie  found  ati'ections  of 


the   larviix   in   ahiio<t   o 

autopsy.      Ilalfnftl 

ill  more  profound  ulceration,  in  par 


ne-lciith   of  all    ea.ses   of  tvphoid  fever  that  came  to 


,  .1' 
i-isted  in  simple  snperticial   ulceration 


t   uitl 


1   necrosis  ot   cartilaL'P. 


the  others 
The  state- 


ly ot'  various  writers  with   re;.'ard   to   the  freipieiicy  of  laryn^real   llh'ei 


lion    varv   ipiite    remaikahly, 
upon    llic  observations  of  .leimer. 


While    Murchi^or..    who    hases    his   opinion 


rousseau. 


L 


nils 


ot  tiers,  as  wt 


!i   as  hi- 


)Wii.  desitiiiates   it   as  an  "occ 


frc 


■e(]nent,  conchtion, 


Hot! 


'iiiaiin  ot)serv 


•d   hi 


Bartlett,    Wilks,   and 

a.~ioiial."  evidentlv  not 
t  Basle  in  2H 


•viiL'cal   ulceration  at  liasle  in 


f  his  fatal   ea.ses.      In 
imhurir   we   ohserved   extensive    ulceration    ot'    the    larvnx    in    '-Vt    of   .'!4!t 


of  "_''iO  autopsies,    and   <  Iriessiiiu'cr   in    2fi   per   cent.   ' 
H; 


!      !s! 


•;% 


Witl 


d  to  the  f't'ciinencv  of  ulceration 


it'  the  larynx  in  accord 
[■Iv  attacke<l.      Mei 


aiice  with    aire   and    >ex,  children    appear    t»    lie    ran 
cxhihit  ulceration  ot' the  larynx  far  more  frcipu^ntlx-  than  woi 
third-   of  the   ca-cs    under   mv  oli-ervation   oecnrrcil    in    iiiei 


■tioii    anleccdciit   predi-po~ 


nvs  infliienci 


Tw 
In  tl 
prolialilv  plav  an    inip( 


taut  i-M, 


e-peclall\'    clU-oIllc    plia 


r-   predomiiiantK'  in    men.    Iari:cly  as  a 


iliarvnii'i'al   and   larvnireal   catarrh,  -iicli  as 
re-nIt   of  -niokiiiL^  and    ot' 


It    i-  douliirul    wliether   ulceration    of   the    larynx    oi'cnrs   with   especial 


I'.   V,,,,,,//.  ./,    If, 


1  si;; 


v.   /;./-/..  isr.il.  .N, 


1  //.,-/     No.  -JO. 


«/• 


,;,i.  .1.  1,1  s„ 


«   ■■  Dh'    I.ll 


r\  n\-  iiii'i 


■!'i-ii.hi':i-i.' 


-I     iss:; 


n. 


ifr  .Ir,    .\1k1,i 


l';,ri-.   ISiiH. 
\[\  iiliu-  Uhil  i)ii 


Iti'liiui.liun..;.'  An-/,./.  I.hii.  Chn-_.   |sst,  lid.  xxx. 


&i 


■k.,r 


miu  I 


S3K?^-?^t^ 


•2A\ 


ryriiniii  ii:vi:i: 


fivnui'iirv.  I„.u..vrr,  HK.v  !,.•  n.  ,  ,  M.i  Mi  rrl;nH  uuu>  mm.I  -lunn.  -vrunn 
,.|.i,U.|,iir;.  11, i~  .>  inirn.uplu,:  '••AT  :.>  .Ml  M>  nf  llu'  liinn-..il  ul. ■.■,■,.- 
li'm  ,,f  ivnlm.  r.'x.r.  whlrh  at  ■.■•:^•^  r.n^  ,■  M  vrry  .■,mr.i.icuou>  tcMtuiv  ..I 
llu.    .i.i.i.'nnc;   ^'<^■   i.i-la>i.T.   .lu,  ac    l:i>I    .-pi.l.M.n.'   .>f   tvi.hu>    1,'V.-,-   at 

H,.i-lin,  ul„.„  \  p.r  .viit.  ,.f  all  ■.  i.viilin>  |.ali.'Hl,s  uii.l.r  .mn  nl,s.i-vali..n 
prrM'Ulr.l    in..iv   or    lr>.    luavkr,!    ii,\..lv,.|      lU    ..f''if    lannx, 

Tlir  tiiiir  ..f  (-i-.'t  and  ill.'  .ini'alinii  (.f  lai'VM-val  iii.Tratinii  in  llir 
.•cuf-- nf  tvj.lioi.l  Irvcr  aiv  .Ativinciy  .litliriilt  •■>  .i.KTininr.  iiia-iiiii.li 
a-  the  iiiiMrr  ir-ion-.  a^  xwll  a-  tli.-,.  that  Hil>M',|U,ntly  |.mi>u.'  a 
M'vnv  .•..in-..,  aiv  likrly  to  W  al-im-t  Ww  tVoiii  >\  iniHoin-  at  tlir  oiit- 
>,.t.  'I'lic  .Ir.'iilv  -IniM.r..ii-  i-ati.-iit-  <ln  n"t  .•nmplaiii,  and  tli.'  pliy-i<'iaii, 
nudrrMM'hc.nditioi,-,  ha-  little  v.'a-on  an.)  ..|,i".ftiinii>  for  cxaniinali'.n 
,.f  the  lai-viix.  It  may  \,v  -aid  in  nvif.-ai  that  ulcTatimi  uf  the  larvnx 
,„-,-iir-  .■liirtly  at  th.'  !m  i-ht  nl'  lh<'  -li-ca-c  and  in  llir  ImII.t  part  nf  the 
fnhi-ilr  -tauv!  i,rin.i|.ally  at  a  lini.^  wlim  cxfnliatinn  nf  tiic  >lnnd,>  and 
ci.atri/atinn  nf  the  nl.vr-  in  tiir  intotinr  arc  taUin-  ida<v.  In  i>nlatcd 
in>tan(v-  I  iiavc  nl.scrwd,  hntli  l-y  laiynp-cupir  .xaininatinn  and  at 
an*  ,p^v.  „lr,.fati..n  nf  tlf  laiynx  a-  .'ai-ly  a-  the  l,.-innin.L'  -f  the  tliifd 
wrck  :  in  niif  iiiMancc.  cvii  at  tlir  l.r^rjnniiii:  nf  tlic  Mv.md  wcrk,  tlicrc 
\va-  a  dfc'i.  iiliTf  npnii  the  po-tfrinr  wail  nf  the  larynx. 

Wiicn  liic  alTrctinii-  nf  the  lafynx  triv.'  ri>r  tn  ^ytnIltnnl-,  these  \vill 

1„.  nin.t   vaiial.le— ln.al    pain.  ditVienlty  in   -wallnwin^  as>nciatc<l   with 

a-piratinn  nf  fn.«l  intn  tlie  ai.-pa-siu.-.  initativv  enniHi  "n  speaking:  and 

.,„  ,l,.,.p  l.ivathin-,  liuaVM.ne.s  and  ,ven   aphnnia.      .Vt  times  the  >ymp- 

tnm-  nf  aente  ..U^ma  nf  tlie  -Intlis   may  set   in   .|"it«'  sn.ldenly,  l..f;.re 

theiv    is    anv    r.asnn    fm     thinkiiiLr  nf    sefiniis    disease    uf    the    larynx. 

Kverv   ivi.hnid   pati.nt    with   laryngeal    symptnin<  slmnhi   thei-efn.v  he 

Mll.jeeted    tn    siH.Mal    nlxefvati-n.       Thi-    ajiplies    part  ie.ilarly    tn    th<' 

thri,at   an.l    h.rvnx    in    -evere   ea-e-   wlter.    tlf    patients   are   Mtipnrntis. 

With  ev.Tv  inrrea-e  in  iv-pu-atnry  fre.|neney,  with  tif   .lev,l.,pment  nf 

dv-pnea  a.'.d  evann-i^.  inv.ilvem.nt  nf  the   larynx    sh.mhl,  amnitir  nther 

things  alwav-'l.e  tl.nnjrht  nf  as  a  ran-.'.      Mor,.  than  nne  imf..rtnnate 

ea-e   i-   knnwn  in  wltieh  -nperf.eial   nh-ervefs  attrihnte.l  -n.Oi  <ynipt.m.s 

tn    l.rnnrhiti-.    Inhnlar    pnennmnia,    nr    tn    the    exi-lin-    intiltrati-n    n[- 

tlf  Iniii;-  alnne.  Mid    in  whirl,   th.'  anmp-.v  -li-'"'''   '•'•"  '''•'"''  ''='"  '''"' 

tn  ...leir.a  nf  th.-   -Inltis  f-r  whieh    traehentmny  -h.mld    have   l.een    p.'f- 

tl,rme.l  prnniptlv.      In  r,,ntra-t  with  th..  prnf..nn.l  .■.m.liti..n-  just  ref.'riv.l 

t,,.  it  i-  .■nmfirtini:   t..   kn..w  Hiat    in  th.'  lartr.'  majnrity  ..f  ."ises  iile.^ni- 

,i,"„.   nf  th..   larvnx    ivmains   Hip.'rfi.'ial.  ..xt.!..!-   l-nt    littl...   ati.l    h.'als 

wi.h..nt    -...in.'!-.       Til.,    larynpai    alV..linn    -h..nl.l    n..t    th.nfnre    U- 

enii-i.l.iv.l  a-  ..f  t.M.  -niv..   pn.iriin-ti.'  -i,L'nifi.'Mii<v. 


SYMI'TdMs  AM)  COM I'l.KATK >SS. 


245 


I'.illdwiii;.'  tlio  siiir^cstii'ii  oi'  l{i)kitaii>l<y,  xmic  writer*,  ospccially 
iIk  l'"nnili,  liasi.'  a|)|ilicil  tliv  ilr-iHnaticni  "  lar\  tii;(it\  [ilinid"  to  tlmsu 
i'a.-i>'  ill  wliicii  cxtciiriM'  larviijiiai  >yiii|ituin>  ajipi^ar  ijiiito  early.  I 
euii>i(lere(l  tliis  (k^ie-iiaticiii  arbitrary  aiul  scarcely  jiisiilieil.  Smie 
reiiiaiks  ujHiu  paralvr-is  of  tiie  vocal  cords  will  lie  iiuule  in  the 
slK'ceciliii;^   cliaptt'l'. 

Trachea  and  I<arge  Bronchi. — In  tliese  parts  also  dry  catarrh 
or  catai-rli  attended  witli  hnt  scanty  secretion  jilays  a  certain  rule.  At 
aiitii|)>v  tracheitis  and  hronchitis  arc  anioiiji  the  c<inditions  most  C()n- 
staiitls-  tonnd  (>cc  Anatomy).  The-c  conditions  are  nianitcsted  clini- 
cally Ky  dry  coiifrji,  tenderness,  and  a  scll^e  ot'  soreness  hehind  the 
sternum,  and  tlic-c  .-yniptoms  are  more  i'rciitiently  com|>laiiK'tl  of  since 
tln'  tracheitis  is  likely  to  ajipear  at  the  end  of  the  tirst  and  the  heijin- 
ninj:  of  the  second  week  ;  theretiirc,  at  a  time  when  intelligence  is  still 
preserved.  On  aiiscnltation,  coarse,  dry  n'llcs,  sonorous  and  sihilant, 
ran  l)(>  heard.  The  sii]K'ticial  ero^ions  of  the  miieous  incmbiiine  that 
are  cnconntcreil  on  p<>~t-iiiortcm  exaniinatiou  give  rise  to  no  .spe<ial 
clinical  symptoms. 

Diphtheric  atftH'tions  of  the  trachea  an<l  the  large  bronchi  are  still 
more  rare  than  those  of  the  nasopharynx  and  larynx,  (ri'icssinger 
refers  to  pseudoincmhranons  attections  of  the  larviix  and  the  trachea 
in  cases  of  malignant  course,  hut  1  have  never  observed  such  condi- 
tions. Ki-enlohr'  has  described  a  form  ot"  tiiirinous  bronchitis  devel- 
oping as  early  as  the  end  of  the  secon«l  week,  which  extends  into  the 
smallest  bronchi  and  heals  without  complicatiou.  A  fatal  case  of  this 
character  is  mentioned  by  {{iiiiilt.^ 

Involvemtnt  of  the  bronchial  glands  is  often  observed  at 
]xist-mortcin  cxa'iiinatioii,  and  is  well  known.  It  is  doubtless  analo- 
gous to  that  of  the  moenteric  glands,  anil  is  jirobablv  sjn'citic,  due  to 
the  bacillus  of  Kbci'th.  In  the  cailavcr  recent  medullary  swelling  of 
the  gland.s  is  (piitc  generally  t<)nn(i,  at  times  of  such  con-iderabic  (>\tcnt 
that  tiie  ])ossibility  of  compression  of  the  tnichea  or  of  the  large  bronchi 
in  con~c(|iience  can  readily  be  conceived.  In  some  iii-tances  in  severe 
ca-cs  of  typhoid  fever  I  have,  in  fact,  ob-crvcd  rcmarkablv  enfeebled, 
soft   breathing  upon   one   side,  when   no  ade<piatc  explanation  could   be 

based   upon  di~ea f  the  lungs  or  the  pleura,  and  which   ])er-iisted  so 

long  that  nciilicr  occhi-ioii  by  n\ncii<  nor  other  tran-^itorv  iiiHuciK'es 
could  lie  con>idcreil  the  eaiHc  <pf  the  condition.      The  rc-|iiratorv  murmur 

became  normal  again  with  sub-idiiii f  the  fever.      I  have  lost  no  case 

t>f  tills   kind,  and   therctbrc  <lo   not  venture  to  consider  the  condition  as 

'  licrUn.  I.tiii.   \\\,.-l,.   ISTi;,   N.i.  :;1.  »  l'rn,,,;.i  i„:,l..   l.ssl     N.i.   111. 


i;  \ 


246 


ryrii'iii)  i i:vi:n. 


U.N 


% 


UHl 


willi  cci'tailitv  (iiic  (if  liriiii(lH;il  >lcri(i~i>  diif  tci  j;!;ui<lnliil'  tiilMr^ciiiciil. 
In  ;i  llital  ca^r  ol'  (iii|i\riiia  I  \\a~  alilc  tn  (Iciiion-Iratc  |iiinil(iit-|iiitiiil 
ili.«iiiU'jr'':itiuii  (if  a  nia>,~  nt'  bnnicliial  1\  iiipliatic  .;lau(l~  a>  tlic  |Miiiit  nt' 
tirijriii  oi'  llie  ciiiniiliiaticni. 

riic  catarrh  of  the  medium-sized  and  smallest  ramifi- 
cations of  the  bronchial  tubes  i-  a  iUhmi  ciuiiiniiatidn  of  tlic 
calarrlial  t'Oiuliliuiis  |irc.-int  in  the  iai|;c  r  air-pa-^airo.  By  icaMiii  df 
tlio  coiistaiicv  of  ii>  occmrciiif,  ilii'  |H(uliarily  of  its  >yiniitiiiiL>  and  its 
comx',  1  l)(lii'\c'  tliat  it  can  lie  dctinitfiy  iooki  d  ujinn  a>  a  -|H'cilic  ty|ili(iid 
s\  injiioin,  and  may  \w  attril>ntc<l  directly  to  tin-  actiim  cf  toxin-- or  of 
the  l)acilli.  A  itiioii;.di  Murehi.Min  and  >nl)>ei|U(nt  writers  do  not  attach 
to  it  tliis  >it;nilieanee,  and  altlioutrli  tlie  former  even  lielieves  tliat  he 
ol'>erve(l  hronehiti-  far  more  fre(|Meiitly  in  ca-e-  ot'  typlins  tiian  in  liio-e 
of  typlioiil  liver,  this  po-ition  i>  not  wiioliy  in  accordance  with  tiie 
i'aets.  I'lie  bronchitis  altenchii;,^  ly|iinis  fever  pnrsne-  its  eonrse  witli 
much  more  proiiounceil  svmptoms,  parti<'idarly  more  marixcd  cou^ih  and 
more  al)nn(lant  secretion  ;  while  in  ca-cs  of  tyjihoid  fe\cr,  liy  rea-on  of 
the  slij:ht  (ie;;reeof  swiilinj,'  and  si)on;:ine-s  of  the  mneoiis  memliraiic  and 
tiie  .-mall  amonnt  of  secretion,  conLrh  i-  less  frei|iient  and  le>>  se\  ci'e,  ae 
cx|ui'toration  is  almo.~t  always  wanting;-.  If,  howexei',  thi'  patient-  are 
examined  carefully  at  the  heijiht    of  the  fclirilc  -tai:v.  jihy-ical    -iiii.s   of 

bronchitis  and  hnnichinlili at  times,  il  i-  trne.  Iml  A\<j\\\ — will  always 

l>c  demon-ti'ahle  in  some  dru'i'ee.  A-  early  a-  the  end  of  ihr  fir-1  or 
the  liiHinniuir  ot'  the  -econd  week,  and  from  tliis  time  on  throiio^lmnt  the 
entire  t'elirile  ])criod.  roiiiihcmcl,  t're(|Meiitly  enfeclilcd.  vesicular  inspira- 
tion is  audilile,  at  time-  \vith  proloULialion  of  cx|iiration,  and  sometimes 
with  an  aliundanci',  and  at  olhcr  lime-  with  a  >careity,  oi'  dry  rale-^  of 
sonorous  and  sibilant  (|nalily. 

The  -eat  of  -uch  catarrhal  condilion-  i-  c-pecially  in  the  lower  lobes. 
Not  rarelv.  and  especiallv  in  -even'  ca-c-.  they  .  \tcnd  throiiLihout  the 
entire  hum'.  In  tho-c  -itualions  in  which  cMcusivc  bronchiolitis  i- 
jiresont,  maririnal  emiihy-cnia  may  develop.  Iv'ai'ely.  the  antcrioi'  and 
upper  jvirtioti-  of  tin-  Inn-.:-  are  in\ol\cd  lir-t  and  nio-t  markedly. 
Such  eases  -honid  be  \icwcd  with  -u-picion,  and  \w  invcsti^'-atiHl  lor 
complications    with   e-pccial   care. 

It  ha-  been  -lale<l  that  bv  n.i  mean-  all  ca-e-  of  brouchiti-  are 
attcmlcd  \\ilh  eouifh,  .nid  thai  when  patient-  cj.i  exhibit  a  -hort,  dry 
ciHioh  there  mav  be  oiiK'  a  -cant\  ,  viti'eon-,  \  i-cid  cxpectonition,  il'any. 
More  \-iolent  and  more  frviiuent  cUiili,  or  aliuiiiiant  mneiijinrident 
e\|iectoration,  demand-  earcfid  iiivc-tiiration  tin-  the  jire-ence  oi  oilier 
alteratioTis. 


SY.yfl'TnMS  AM)  ((iMl'I.Ic.iT/o.SS. 


247 


III  piifHii  tlic  latanlial  liumitc-t.itioiis  arc  nt'  cinisidi'r.ihlt'  .-ijiiilli- 
caiuc  ixiili  iVdiii  a  tlia;rii(>-tii'  ami  tVinii  a  |l^ofr|l(,^li(•  >taii<l|Hiiiit.  In 
iliair'i"~i-  ''"■  <itt(<liuii  ot'  (litViiM-  lii'uncliicis  i>  oini'ially  of  >ij.riiiticaii(r 
lid'aii-c  ctlicr  iiil'c<tiiiii~  tliat  may  rcailily  l»c'  i'<piitipiiii(l('<l  with  typlKtid 
fever,  a^,  e.-iHH'iallv,  feldile  |n<>tT-,iete<l  iiile.-tiiiiil  catanli,  arc  iiiuittciiilc<l 
with  it.  <  )ii  tiieotlicr  haiiil,  it  i~  imtcworthy  in  tiie  (haj^iio-is  of  typlioid 
fcv(  r,  ami  iimler  suiiic  cnii<htiiiii>  (le<i>ivc,  when  a|)iKirciit  ititistinal 
catanh,  even  of  >li^ht  intensity,  i>  from  tlic  outset  asscM^iatcd  witii 
e\ten-ive  lnoiieliitis.  It  is  to  lie  iioteil  that  tile  (lejrpec  ami  the  extent 
of  the  lironeiiiti-  in  ca-t's  ol"  typhoid  tever  nee<l  liy  no  nitsms  eoiTes|Hiiid 
with  the  severity  of  the  ea-e  in  i,''enei-al.  There  are  mild  eases  with 
marke<llv  ])redominant  lironeliiti>.  The  reverse,  it  is  true,  is  less 
common.  From  a  prnirno-tic  jMiint  of  view  it  is  al-o  noteworthy  that 
after  intense  catarriial  conditions  of  early  on~et,  scveic  involvement  of 
the  liiiij;-  imnicdiiilely  adjacent  is  likely  ^ul)M'<pieiitly  to  occur. 

In  addition  to  sim|)lc  tvplioid  ludiichitis,  the  riire  occurrence  of  ])Utrid 
hroni'hial  disorders  is  wonhy  of  note.  I  have  re|)eate<lly  ol)>erved 
them,  and  have  not(Hl  their  disap])eannicc  without  tnices  at  the  termina- 
tion ot'  the  attack  of  typhoid  t'cvcr.  In  iMilate<l  cases,  on  tiic  other 
hand,  thev  jiiiihalilv  i;ivc  ri~e  to  small  hronchiccta^es  or  circuni~crilied 
destruction  of  pulmonary  ti-siic,  ocia.-ionally  with  I'onst'ciitive  ])Utrid 
]ilcurai  exudates.  The  atelc<'tasis  and  the  lohular  pneumonia  that  arc  so 
fii(|iient  in  the  course  of  typhoid  fivci'  arc  intimately  rclatc<l  to  the 
lironchiti-,  ]>articularly  to  the  capillary  variety.  Clinically  these  con- 
ditions arc  ol'tcii  r(KMnrni/al>lc  with  ilitlicidty  it'  at  all,  and  this  is 
e-peciallv    true   of  atclccta>is. 

Bronchopneumonia,  which  occasionally  manifests  itself  hy 
increase  in  the  fever,  chan^'^e  in  t'u'  chanicter  of  the  ex|KH'tor:ition,  i^nd 
occasionally  also  hy  di-tinctive  auscultatory  sitrns,  ha^  been  little  invcsti- 
jratcil  t'roin  the  etiolofxic  point  of  view.  In  the  majority  of  cases  this 
condition  is  donhtlcss  to  he  includeil  amonir  the  true  complications.  In 
the  small  nnnilKT  of  cases  thus  far  investijr.itiMl,  principallv  the  pvopnic 
liacteria,  streptococci,  and  staphylococci  have  lieen  found.  Without 
dipiilit,  lironcliopneumonia  in;iy  also  he  of  sjH'eilic  typhoid  chanicter,  as 
i-  shown  hy  the  invest ipit ions  ol'  Polyiicre,'  l-'inklcr,- and  others,  who 
wii-c  uhle  to  dcnionstnitc  the  hacilhis  of  Kherth  as  the  excitiuir  caiiscof 
the  inllammation.  '\'\ir  extremely  y:rave  c.m-i-  of  acute  edema  of  the 
lun^s,  which  arc   fortunately   rare,  are  also  dependent    u]H)n  I'Xtcnsive 

'  Th'sr,  I'iiris,  ISH!).  ritcd  l.y  V'iiiklrr. 

'  l>ir  acittrn  LungeurnizuniiniKjcn,  Wii.'sbadi'ri,  1889. 


Ill 


^1 


■t^^-^t 


'fi 


W^ 


m 


i 

^■^t  i 


248 


TYrii'iin  ii:vi:n. 


Iiniii(lhi|iii(iiiiiiiiii;i  mill  cardiac  \vcakiic>~  \\\i\\  acute  uti-ct,  nr  with 
aciiic   inicii~ilicatiiiii. 

i'.niiicliii|iiiciiiiioni:i  likc\vi-c  ci>n-titiit(-  tlic  u-iial  l)a-i>  fur  tlio 
hypostatic  congestion  of  ilic  Idwcr  IoIh-  nf  tlic  Imi;^^  iliai  ..ccurs 
M)  t'i\'i|iicntly  III  llic  latter  part  nt'  tlic  t'chrilc  .-taL''c  ;  it-  <1c\i|ii]pmiciiI  is 
uIhi  tlivoiid,  liiiwcNcr,  l)v  the  \\eakiie>s  ol'  the  heart  and  the  iiilliieiici' 
of  tile  |K)^tiire  nt'  the  limlv  ii|inii  the  di-tril)iili<iii  nf  the  IiIckmI.  I'npiu 
all  that  lia~  Ihk'H  .--aid.  it  will  a|i]pcar  that  liy|(ii-talic  cdiiMi-tiiiii  uceiirs 
tinly  ill  dehilitated  iiidiv  idiiaU  with  -cvcic  attack-,  and  it  iherefnre 
fi>rin>  an  iiii|Hirtaiit  link  in  the  chain  of  iiiilavnraMe  occurrence-  in  the 
eoiii'M' lit'  ty|iliiiiil  fever.  In  patients  pre-eiitin^  e-|)eeially  -e\  ere  iiifec- 
tiiiii  and  alnadv  iiiucli  rediiciil,  the  hvpn-ta-i-  dc\clii|)-  a-  earl\  a-  the 
first  hall' of  the  fehrile  slaye  nr  at  its  heij;lit,  and  it  i-  then  nt'  espe<iallv 
inifavnralile  niiieii.  It  i-  mmc  (111111111111.  it  i~  true,  pailiciilarlv  in  eases 
(if  jimtraeted  (iiiirsc,  tnward  the  iiid  nf  the  t'chrilc  pcrind,  nr  even  at  the 
lie'^iiinint.'' nl' cnnvaleseeiice.  I  have  iicea-innall\  nli-crved  it  also  diirinjj 
rela]i>  .with  pri)|nn;ied  cmirse  tiillnw  in;,'  an  aiilecedeiit  severe  attack. 
Ill  the  al)>eiice  nf  Msteiiiatic  c.irefiil  exainiiiatinii  uf  tlii'  jiatieiit,  fur 
which  there  is  nt'tcii  im  s|ic(ial  indicatinii,  this  hypn-tasis  niav  he  rcadilv 
nverliKiked,  as  in  itselt'  it  irives  ri-c  neither  tn  elevatimi  nf  tetii|ieralure, 
pain  nil  lireatliiiii:,  imr  tn  increa-ed  enuirh,  and  liy  im  iiieans  always  to 
ehaiiifes  in  the  trcipiciicv  and  the  characler  <>{'  the  re-piralimis.  On  the 
other  hand,  physical  exaininatinii  will  at  niicc  yield  the  desired  iiitltr- 
niatimi.  There  will  he  tiuiiid  slijrlitly  tyni|)aiiitic  nr  even  niarkedlv 
impaired  re-ntiaiiee,  pn^terinrly  and  iiiferinrly,  at  tir-t  iit'ten  cniilined  to 
one  side,  thniiirli  siilp-eipieiitly  Usually  iiiaiked  iipnii  linth  sides.  The 
vi«'al  fremitus  is  jrenerally  iimderatcly  increaMil  it'  the  patient  can  lie 
indiieed  tn  siilimit  tn  invc~titr;itinn  nf  tlii>  pheiiiimcnnii,  lint  iint  rarely 
it  is  eiifecl)le<l  and  c\cii  !il>-eiit  when  the  liiniichi  arc  tilled  with  secre- 
tion. The  respinitnrv  niiirmnr  i-  aecnidinc-ly  iiidi-tinct,  -nt't,  iin  Iniijrcr 
vesieiil.ar,  and  expiration  is  prnlnnccd,  with  a  luniicliial  character.  If 
the  eonifestinii  |irn(ri'|.s-e-.  fnilher,  the  rc-piraloiy  niiirmiir  hecnines 
markedly  hrniicliial  and  the  r.'iles  ainphnric.  Nut  rarely  in-piratinii  is 
eoinplctclv  nhsciiri^d  liv  crepitant  nr  -ulicnpitant  rales. 

With  imprnvement  in  the  reniaininir  syiii|)tnms  t\\'  the  disea>e  sueli 
ennsnlidation  iisiiallv  nndci'irnes  re-nliitinii.  as  a  re-iilt  nf  a]i|irii|iriate 
treatment  or  witlimit  s])ecial  intervi  ntinn,  and  is  ii-nally  fnllnwcd  liy  no 
se(|iiels.  In  some  eases,  with  eiintiiiniil  |)rnirre-s  of  the  disease  the 
syiii[>toms  of  eniisnlidatinii  mav  increase  and  extend.  (  ntisideralilc 
clcvatinii  nf  te:M|>eratiire  mav  occur  assneiated  with  rc|)eatc(l  ehilline-s 
or  even   a  iii.irkcd  chill.      I'lidcr  such    civcnnistances    a    conditinn  nf 


.\)Mri<>MS    .\.\l>   I  OMI'I.I'W  lli>\S. 


Il'.t 


hypostatic  pneumonia  may  ■.\\>\< 


Mvh 


liukcii   cii. 


Ill 


.lonh 


i'|irii(|c'iil     li|Mill   Ihc    > 


■ciiiiiilarv 


iii\  a-i'U  lit    exciting 


iifciits 


il'    iiillainiiiMliciii,  priuiiiiMlly    i1iiimii;1i   llir   iii-|iii(<l   ail' 


ciilllllliilllV 


tlll'nU 


'Il  the  lirciilaliiiii.      \\  lictiicr  tlic  tvplinid-ha 


icilhi-  iilav-  an  < 


•tiuldni 


,;/. 


Ill    tli(--('  coiiiiiliiatiiiiis,  am 


I    if 


itii    wliai    t'l 


IS   as    Ml 


iinkiiiiwii. 


H> 


[)o-tatic   ])iii'iiii 


II  una    IS   u 


lie  lit'  tiif   must    (laiiLicnills  (■iiiiililicatiuii,- 


llt     t\()llliHl      tcVcl 


Dfath 
li 


nil'--    111    till'    nia|i 


iiitv   iif   cas 


iil.l 


ivtrv  cM-iic,  -low  (li«aii]>('araiici'  i 


.f  the    1)1 


])liv-iial   -ijriis  ;  with  a   pHH 


trac'tc<l  coiii-M'  I'lir  tlic  ciiliii'  jinico^,  i^  the  rule       I.inal  ciniiiilicatioiis- 

1  iilciiri-y  with  rtViisidii — appear  to  ii 


liic  I 


iiii'f,  iiaii'Ti'i'iii',  aiK 


tu  !(,'  Ic-s  I'liininiiii  after  h\  po-tatie    pneiniioiiia  than    alter  ntlier    iiiHain- 

Uiatniy  pi-iice— es    in    the    lilllLrs. 

Of   Is.'UI  eases  iif  tviilidid   t'ever  nf  which   I    ha\e  ikiUs,  sii'iis  of  eDiisiili- 

es  w<Te  ]il-esenl  ill  121. 
le  eciiulilidii  Deeurreil  in 
I'tween   tlie   end   of  the 


daliiiii  or  iiitlaiiiiiialiii-v  e(iMi.'eslinii  nl'  the 
In  the  iiverwheliiiin;:  iiiainrily  of  iMses  the 
the   second   and   the   third   week,    iiinst    frec|Uently 


et  iif  tl 


id  and  the  middle  of  the  third  week  ;  and  of  the  patient.s  in  (pieslioii,  (J") 


died.       I'he   ohservalioii 
It 


Lieli 


■rnieister   dili'er   Im 


id  ainoiiir   1  (JO  ea.se.-,   KIO  of  hvpostalii 

1  "h 


lit    little    tVoni    my   o 
iMireslioii.  with  .")()  ileal h: 


is   noteworthy  that    eonjrestion   and    liy|)o-tatie    pneumonia 


are   far    li 


eoiamon   in   ehildreii   than   in   adults.       T 


liis   is  no  doiihl   partly  due   to  ll 


.shm-tpr  duration  and  tiie  jreiierally  slighter  inten^ity  of  the  attack  of  typhoid 
fever  in  eliildreii.  hiit  es|H'cially  to  the  iiict  that  tlie  deteriniliinf;  cause  in 
adults,  namelv,  the  wi^akness  of  the   heart,  is  inucli   less  eoninionlv  etl'eetive 


in  ehililreii 


n< 


|H'ciallv  coiivnienn.''   in    this  co 


iiniection  also  is  the  fact  that 


piieunioiiia.  the  on.set    nl   wliieli 


hail  to  the  infeclion    it>elf  i> 
iian  ill  adults. 


hie   less   to   the  eardiac  weakiies.s 
mv  ex|Hrieiiee   no  ies.s  eoiiinioii  in  children 


I<obar  pneumonia  i-  h--  fieipient  in  the  course  of  typlioiil  fever 
than  li\po-tatic  ciiiii.restioii  or  <'onsolidatioii.  Anionic  tlie  (litlereiit 
varieties  true  croiipons   piu  niiionia   ]ilays  the  priiici])al  rnlf,  and  is  one 


iiiii)oi'tant  actual 


coini) 


licatioiis  ot'  the  (li: 


of  the  more  iiii| 
e.xcliisively  depeiideiit  upon  the  l""f:iiikel-\V 
witii  cxtreinc  rarity  upon  tlie  hacilliis  of  I'ri 
rule,  at    the  iiciidit  or  toward    the  end  ot'  ttu 


•ea-c. 


It 


eicliselhaiim   dij 
•dliiiider.      It  oc 


is  almost 
iloeoccns  ; 


•ours,  as  a 


fcl.ril 


,e    iienoi 


id.     It 


iicenrs 


Verv  ran 


■Iv, 


fdint;  to  niv  expericiiee,  dnriiiLT  convalescence  or  in  the 


collide  ot'  rela|>>t's  ot'  coii-ideralile  duration. 


Altl 


ll    the  oii-et  and    the  conr>e  of  e'eniliiie    ''laiiKHls  pnetinionia 


are  usually  most  eliar;icteristic,  the  symptoins  when  it  occurs  as  a  com- 
pliealioii  of  typhoid  fever  are  exceediiiLrly  inconstant.  Kveii  tlic  manner 
in  wliicli  it  maniti'sts  itscit'  i-  extremely  variahle.  Generally  it  sets  in 
with  a  sinirle  or  repeatcil  cliilliiiess.  or  a  true  chill,  although  these  sym]i- 
toms    may   he   wliuUv   waiitinir.      'I'lie   ali>ciiee   of  cliilly    symptoms    is 


260 


TV  rill  nil  1 1  \i:i:. 


i 


^^'•f-/' 
1^. 


T.TWt'^ 


H 


<ili-(r\(i|  c^iMciiilly  ill  ](irvinii-l\  ilc  liililMlrd  nv  III  cldcilv  |Hr-uti-,  or 
\\liiii  llic  |iiic'iiMi<i|iia  (|(\(  |o|i~  ill  a  lali'  -\:\\ii-  in  macii-  |iiiplra<t«'il  ca-cs. 
\  ii'liT  ~iii'li  ciiTiiiii^-tanrc--  (•\in  iiii|i'\\.iiili\  cIcNalii'ii  oi'  cliai'ac'.cri-lic 
c'(iiii-i'   111'  tlio   tniiiMTaliirr    iiia\    lie    waiiliii;^. 

Asa  nili',  1  lie  oil -el  n|'  ilir  |  iiii  iiiiioii  ia  i-  a  til  I  lilt  ■<  I  w  illi  I'apiil  ri-c  in  the 
liiiilv -lriii|)iTalmf,  wliirh  may  tin  n  roiiiiniH'  l^r  ila\-  al  an  almorniallv 
liitrli  KmI,  in  ilii'  loiiii  o('  a  riiniiiciii  continnnl  t'cNcr.  \\  lien  ilic 
jiiifiinionia  (li\(lo|i- iliirin;,'  llir  la-l  iiorii,.n  of  llic  lil>iilc  |Haioil  and  llic 
rc-olntion  coin.idi-  willi  the  lii'iiiination  of'  ilii-  |iiii.,d,  lliii'f  niav 
(icca>ioiially  he  a  ditiiiilr  riiiical  diiUni'  in  lrin|)rialnii'.  1 1',  on  the 
otlirr  liand.  lln'  |iniiiiiionia  iiiidi  r^oi-  i-i -oliiii.iii  in  llic  coinx'  of  the 
I'a-liLiinni,  llie  (a'ilical  drrlinr  i-  waiiliiii;,  a-  a  rnlr.  and  (lcl'cr\i'>c<iice 
l>v  i\-i--  lakc»  IN  |iiari'. 

All  cases  ol'  |in<  ninoii'::.  even  tlio~c  tliai  do  not  nivc  rise  to  marked 
I'levatioii  lit'  tcmncratiiii  .  arc  attended  willi  coii-idcralile  ini'rea-e  in 
]inl-e-t'ri'(|ncnc_v  ;  and  in  dcliilitalcd  |ici-oii^  are  eciici'alK  a--orialed 
witli  ivdiieiioii  in  ^i/c  and  eon-idcralilc  louciine  oi'  ten-ion  ot'tlie  |inlsc. 
A  e.iire-|)ondiiii:-  iiicrea-c  in  tVeijUeiicv  ot'  ii-|iiialion  and  in  c\aiiosis 
are  nalnrally  (jiiile  eoinmon.  'I'liere  is  tlicrctlire  all  the  more  rea-on  to 
look  I'or  tlic-c  -yin|itoni--  in  ca-cs  ot'  ~n-|,ected  |incnmonia  clnrinc-  l\  plioid 
fe\ir,  liecaii-c  under  tlie-e  eirciiin-taii'-i-.  -iilpjecliNc  coiiijilaint.  |iarticii- 
larly  ot  |iain  in  tlie  -iile.  a-  well  a-  ol'  coiii;li  and  e\|icetoration,  i-  ot'teii 
^\antill'_^  llic  ali-eiiec  of  jiain  and  tlic  -li^lil  clianicti'i' ot'  tlie  i<ini^li 
arc  [iroUalily  de|iend(iii  n|ioii  tlie  |e--ened  irrilaliilit \  ot'  the  |)ati('iit, 
a--ociaIed  willi  the  oli-i'iiration  of  eon-eioii-ne-- ;  and  tlic  aiisciicc  of 
e\|>ectoration  i>|ion  the  laet  that  the  |ialicnt  e\|iel-.  tlie>|intmn  iiii|ier- 
lectly  and  s\\allo\\>  it  aeain,  in  jiart  ]io--ililv  also  ii|H>n  it-  -ecrclioii  In 
relatively  small  amount.  W  hen  the  patii'iil  e'leci-  the  ,-|)ntiiiii,  it  may 
lie  eliaracteri-tiealK'  \  i-i'id.  i'ii-l\,  or  e\en  mori>  hcinorrhai^ie.  I  have 
an  ini|ircs-ion  that  the  la-t  mentioned  |icenliaritv  i-  more  t'rci|ncnt  in 
cases  ot'  imeiimoiiia  iom|ilii-atinir  Ivjiiioid  fever  than  in  tho,-e  of  j^cnniiic 
]in('iiinonia. 

\\  ith  reL'';ird  to  ii-  >eal  and  the  jili\-ical  siLTiis.  tihriiioii-  jimnmoiiia 
atteiidiiiL''  typhoid  fever  diU'er-  littli'  from  that  ari-inji-  indc]icnilcnllv. 
As  to  the  coiir-e,  the  heij^ht  of  the  iiitill ration  a])|)cars  to  me  to  lie  at 
time-  rcaehiKl  more  -lowly,  and  resolution  al-o  is  not  i-arcl\-  com|ile;e<l 
more  >lowIy  than  in  the  inde|ienilcnt  form.  .\  coiisidcralilc  nnmlier  of 
rases  do  not  advance  lievund  the  -vm]itom-  of  contre-tion.  That  the\-, 
nevertheless,  are  eases  of  tilirinoiis  |)iieiimoiiia.  I  have  re|)eate<ll\  liccii 
aide  to  estahli-h  liofh  hy  |)nnelnre  of  the  Inn^'-  dniiiiLi  life  and  li\  the 
deiiionstralioii   ot'  the   eharaeteristic   enean-iilatid   cocci    in    the   simtiim. 


SVAtriOMS  AM)  cdMI'IJC  \  rinys. 


>l 


FiliriiioiiM  |iiii'iitiii>niii  is  not  otic  of  llir  iiiurr  <'(iiiirriiiii  niiii|.|irMli<>i]:'  in 
t!n'  cipiirr-c  of  l\|ilioiil  I'cvir.  lis  i>(<iirr<Miic.  Iinwi'vrr,  cloiilillo.-  cxliiliils 
jrrrat  viiriiitioiis  in  ai'coiiliiMcc  with  the  .-.  m.-oii  nt'  tiic  yiar,  the  localilv.  luid 
the  cliuracttT  of  llif  cpiilfiiiii'.  I  am  |Ki>i>iially  unl  in  |«i>si'>siipn  i>f  larL'c 
slali.<lii'n,  and  wnnM  draw  cuni-lu^'iiins  witli  care  I'min  ihiw  oC  "tlitr  writirc, 
as  a  lar;rc  |>n>|Mirliiin  cit'  ilif  i-axs  liiihcrto  rc|Mirtcd  iiavc  not  liccn  :iindiril 
with  siitficii'nl  care  IVcim  tiic  liacliiiidoirii'  >lan<l|M>inl,  and  llic  n'sidt.-  nt' 
>tudv  of  till!  rcniaindtr  art'  inir(lial)li'.  F.vtii  liii'  older  unaloniic  >Iatt'Mi»nls 
arc  to  !>(•  a('ct'|ilt'il  «ilh  rcMrvalinn.  as  in  cases  ol'  typhoid  tiver,  in  con- 
>ci|iiencc  ot'  certain  iiisloioLMc  coinlilions.  the  pncnnionia  (ie|H'n(h'nt  ii|M>n 
cnca|isnlatcii  cocci  ina\.  n|)oii  section,  cxhiliit  an  unusual  color  ami  a  >niooili 
or  sliidilly  i_'ranuhir  surl'a<c. 

Ai;e  anil  -c\  c\crt  no  inlliicncc  upon  coiii|p!i<'ati(iii  wiili  cr<iii|Kms 
iinciinionia.  'Aliicli  occurs,  a~  has  liccii  indicatol,  with  -caicciy  Ic—  ti'e- 
(picncy  in  children  than  in  a(iull>. 

The  nUi-  |ila\cd  liv  the  di|)lol>acillus  of  Kriedl.indcr,  as  cornjmred  to  the 
F'rankcl-Weichsclhautn  coccus,  in  the  dcvclopiucnl  ot'  pneumonia  in  the 
course  ot'tvphoid  fever,  is  filiscurc.  In  tlnw  cases  in  which  examination  luus 
heen  made  as  to  this  ]«iint,  the  diplococcus  es|K'cially  has  Keen  found,  and 
oidv  in  rare  instances  lh(>  hacillus  of  I'riedhmdcr.  which  I  have  perMiiially 
heen  alile  to  demou>lrale  in  oidy   1  case. 

Other  Varieties  of  Lobar  Pneumonia. — In  addition  to  hypo- 
static and  true  lilirinon-  |>neuiiiiiiiia,  (.iher  varielic-  of  loliar  piiemnonia 
certainly  o<'cnr,  'I'lii^v  have,  as  yet,  not  lieeii  llniron^ldy  in\(-tiirated, 
and  a  ]>iiilion  ot"  that  which  i>  -aid  to  have  Kei  ii  -iirely  c|ctuoii»ti-.ited 
need--  -till  fui'tlier  inve-tiirition.  'I'lii-  i-  true,  aliovc  all,  of  the  ca-es 
(if  loliar  pneumonia  attrihiitaitlc  to  ly  phoid-liaeilli  (  iirnneaii,'  < 'haiitc- 
liie>-e.-  I'dlvnere,'  i'inklcr').  'j'hu-,  I'cdync'ie  fmnd,  in  adilltion  to  the 
loliular  pneumonia  ali'cadx  inentioucil,  (Aten-iv'e  cou-olidation  due  to  the 
liaciihis  of  Khertli.  I'.aily  occiivreu<c.  rapid  ilevelopineiit,  and  tanly 
-uhsidence  ot'  the  intiltnition  ai'c  coii-ideicd  a-  cliaractcri-tic  clinically 
ot'  this  t'orin  ot'  tln'  ili-ca-e.  lu'i'ciitlv,  even  die  liacterio|oj_ric  diaL''uo-is 
ot'  the  spe<-itic  t\plioid  atVectioiis  ot'  the  11111^--  and  the  pleura  lia-  lieen 
rcii(lere<i  adilitionallv  ditliciill  liy  the  t'act  that  the  ISacteiinni  coli.  which 
in  -oine  re-pects  clo-elv  re-enilde-  the  l),i(illn-  ot'  I'",iierth,  lias  UTider 
-ucli  conditions  heen  repeatedly  found  a>  the  excitiiij;  atreiit  ot'  the 
iiitianiinatory   proce->. 

It  is  al>o  olijected  l)v  opponents  of  the  view  that  s|K'citi('  typhoid 
atlect ions  ot' the  liin^r-  occur,  that  in  tlie  ca>e-  where  pure  cultures  of  the 
Iv|tlioid-l)ai'iHi  have  heen  t'oiind.  the  culture-  were  made  >o  late  that  the 
priniarv  invaiKr  had  died  <iiit  (see  section  on  I'atlioloiry ). 

The  condition-  are  not  much  <'learer  with    rcLfaid   to   the  loliar  jmeu- 

'  ■■  |)i'  !a  iiMlun  (lis  ci'iii|ilii',  l.r'iiirlii>-plrnni-piiliii'iii;iin- ilr  lu  fir\  r.'  1\  |ili"iilr, " 
n.-sr.   l'iiri>,   IK'.t:;.  '  A..-,  rif.  '  /.■:•.  nt.  '  /,...-.  rif. 


*l 


'5  »i  I 


\\i, 


f^i 


h-- 


252 


7)  /■//"//.  1 1  vii: 


III 


i»i 


'ill   _  V-"-^ 


inolii.i  line  III  -tl(  |ltnciic(i  111-  -l:l|i|l\  liM'iil-ci  |li:in  xvilli  Ii;j;imI  t'<  lluit  illlr 
tu  l\  |iliMiil-li:irilli.       I    iiiloiililolK    llic-i-  iiiicf(i-i.i"    iii-tii-    |il:i\   MM   ilii|iMr- 

t;illl      / /■/'      ill     lllr     IIIIVcil      illlcrlii.il-     llial     lVli|ll(llli  >      AVf     .■|--iMi;ll<ll      \\i||| 

till'  il(\  cliiiniH  111  III'  inii'iiiiiiiiiia  ill  ilic  ciiiir-c  III  l\|iliiii(l  lixcr.  Tlicv 
li.i\c  lilt  II  "li-ii\  ol  liiilli  ill  :i--iHi:iliiiii  uiili  |>iiiiiiiiiMiicri  iiiiil  Niilli  ||ii> 
liacillii-  ill'  l'!lii  rill  I  l\:nliii-ky  ' ).  Siri|i|iiii.<ci  ii|i|M:ir  In  lie  tin-  -ulc  ur 
tile  |iriiii'i|ial  i':iii-i'  III'  {iiiriiiiiiiiiia  iiiiirc  l'ri'i|iiriil l\  than  ~la|ili\  Ini'iirci. 
Tlicy  irJM'  ri-i-  111  liiilli  Inliiilar  anil  luliar  iiillaiiiiiialinii.-  llic  lallcr 
<ii\iiiii-ly  llir  n-illl  111'  lliv  iiiiillllrm  T  nl'  liilllli|ilr  ii  i|il  ii;i.i  ill-  Inlilllar 
liiii.  I'riilialil\  lliiy  air  al-n  llic  |iiiiiii|ial  iiiiciii-dii^-aiii-iii-  raii-iiiir 
till-  -rciiinlary  iiithiiiiiiialury  cliaiit:!-  alliiidiiit;-  -iiii|ilr  li\  |)ij-talic  cdii- 
p-tii.n. 

Stri|i|iii-cir(i  anil  -laplis  Ini'iicii  iTilaiiilv  |ilav  a  /'I/c  al-ci  in  flic 
(lc\i'|ii|iiiiint  111'  tile  ~ii-calli-<l  a-iiimtiiiii-iniciiniiinia  of  tv|iliui<l  t('\t'r. 
I  lia\i'  ira-iiii  III  lifiiiAc  thai  llii-  tlniiiri'  iwr  c^iMM'ialK  r(-|iiiii-iiilc  fur 
tile  -I'MTc  |iiit'iiniiiiiia  iMIuwiiii;  I\|iliiiic|  iilni-atiun  nl'  llir  lai'viiN  and 
|HTi(liiiii(lrili-  111'  llic  laiynx.  .\|iail  t'lnni  all  tiic-c.  tlii'  .-tr(|iliici>ccic 
|>iiriiiiiiinia  111'  Iy|iliiii(l  li'Xi  r  i-  ilmilillr—  In  in  inn-t  lVc(|ii(iilK  rnM-iilcrcd 
a-  niii'  111  the  nianili-Ialinn-  nl'  ticiicral  -iimidarv  -i|ilic  inl'cclinn. 
I'ndcr  -iirli  ciriiiin-iaiiri-  nilii'i-  li-inii- due  In  ilii-  nrt;ani-iii  can  he 
tiiiiiid  in  till-  lindv  allcr  dcatli.  and  nl'tcn  rviii  diiiiiii.'- lilc.  (  )nlv  recently 
\vc  Wire  alile  In  deniiiii-lrate  in  a  man  t\MnI\-li\c  \ear^  nid  eiiilMilic 
ali-ie— e-     nt'    tile     l<idne\-,    a--neialed     uilii     liiiateral     Jilirc    -tre|)tiii'iieeic 

|)nenniniiia  in  ailditinii  In  |ileiiriiie  elVii-imi.* 

.I'l-t  a-  -eplic  |)iiiee— e-  ixeiierailv  appear  al  a  lale  -tap'  in  tiio 
cnlir-e  nl'  tile  di-ca-c,  nu  illt;  In  llieir  lllnde  nf  deveinpinelit,  -u  alxi  tilC 
jtlii'iiinonia  de|ieiidinl  iipnii  -Ireplnineei  and  nlin'r  pxnu-eiiic  (iri.'':ini>ins 
<icclir<  lale.  Il  i-  ailnn-I  e\elll-i\ei\-  llie  late  I'elirile  period  nr  tiiat  nf 
cnlivaie-cellee  ill  wiiiiii  it  neclir-.  It-  -iilir"e  under  tlle<e  enlidit  inn-  is 
often  a  lied— ore,  or  piiletrmnnnii-  inllaniiiiatinn  nf  tiie  -jxin  and  llic 
>ni)elltaile<ill-    eonilectixe    II  — lie.  nr    it    max  ,  of  enlir-e,   follow  -till    oilier 

]iiiriilciit  processes,  as,  for  in-taiiee,  plilcliiti-  and  cireinnserilH'd  peri- 
toniti-. 

(  liiiieallv,   -treptoeoerje   .md    -ta|ilivlo( cie    pneumonia,  a|>art    from 

mierii-in|iie  ami  iiaeterinln^iie  exaiiiiii.itinii.  <'an  lie  dilfereiiliated  frniit 
tlle  ntller  Varietie-  nllK  with  \  er\  _''reat  dilliellllv.  K'eeelllK,  niinicrniis 
a  I  tempt-  have  liiin  made,  u  it  li  I  lie  aid  i  if  I  lie  i  splnraturv  lueille.  In  olitaiii 


I 


v:  L.;. 


I   r.,rfs.-l,r.  .1    M,./..    Iss'.i,    l!,l     viii, 

'  S.  1-  al-i  till-  rniiuiniiii.Mli"!!-   ■■r  N.in:i;iiin,    ISn-lin.   l^Vni.    ii'ia-li.,    I88r,,  No.  0  ; 
J-'inkl.r.    Wrh.iH.II    7,   (■■.,„,.  i    ',,.•>.  Mr. I..   ISSSuiid  lS8;i;iind  Kurliii.-ky,  lui\  rit. 
■'•  S,.,    K,.,.li     /,!„.,,,    /),,,      I  ,.;,,-i,.     Is'iT 


i 


.SlU/'/"'/N     l.\/'    I'lUI'I.K    \ll'i.\S. 


263 


iiLiti  ii:il  tnuri  tlif  Inii;-'' ilniiiiir    lite  tor  (Aiimlii:!!  i'Mi.       I   liMVr  |iir-oii;illy 

;i\:iili'.l  in\-<lt    "I'  llii-  hhiIumI    niii;ilrill\    will I    injury   |(.  llic  |ulliiil, 

l)llt     Wi.llld    inl\  i-r    i.'n;it     (Mlllioii    in     il-    :i|i|iiic:iliMii. 

It  -li.MiM  l>f  cinlilia-i/iil  ;i-  "f  iiii|Hiil:iii(<-  In. in  lli.'  cliniiiil,  :iii<l 
(-•|>.'<-i;iliv  IVohi  the  .li:i;:n.)-lii-,  iMiiiil  of  \icu,  that  |iiiiiiinoni:i  liia\  ..cur 
cv.ii  :it  an  cai'lv  |i(  ri."!  in  ilic  i(.ur-c  m|'  ivphoi.!  I'iMi.  al    linn-  -.,  caily 

tlial  it  iiiav   at  tii'-l  !"■  < -itli  lol   a-   an    in(lc|..nclrnl    rmiilitiun.      'I'liii-, 

jiiu'iiMiMnic-  inlillialioii-  have  rivi|U(nll\    lucn  .ili-iivcd    in    tin    !ii-l   wtcU 
of  Ivi.liniil  li'MT,  lAcii  in  the  tii-I  <la_\-,  Ipil'oic   any  cil'  tin'   <-liaiaclc|-i-tic 
fcutiin- of  ivpliMi.!    Ii:'vi'   lic'cn    maniH-i'il.      Al    linn-   ilny-ci    inuitli 
one  (ir  nmir  cliiil-   or    i"|iralc(l  <liilliii<— .       I   nilalnal   nv   liilaliial    ci.n- 
>oli(lali(in    lliiii    lapiilly  I'mIIow-;    in    my  (  \|i.i-irn(c.  ciltm    iniuc    ia|iiilly 
tlian  in  (lie  ra-i' nt' nncxniilicaliHl  I'l-ank    |)ni  iiiiKinia.      -Ndl  faivly,  nndrr 
vucli   lii-i'iini-tanic-.,  tlicic   i-    \\>>   >  viicclcratiori  w  lialcvcr,  or  ilic   -pnlnin 
i<  lint  -I'lmtv  anil  i-  not  rlianictcri-lic,  (■nn4ainini:  no  IiI.kmI,  (■nca)i-niatc<l 
<'<ic<'i,  or  lllirinon-  coai.'iiia  ;  in  otlnr  ca-c-^  tlic  -pnlinn  i-  lilood-lin^cd  or 
actiiallv  i>nnif-jnicc-likf   in   cli  inictir.      Ctriainot   tlif  -ulijtctn  c  rnaiii- 
t't-tations    al-o   arc    nioic    incoii-tant    tliaii    in    ca-c-    of   p^rniinr    pniil- 
itioiija.       Ncvcrtlitic— -.    Iiradaclic  of  nnn-nal    -tvcrity  and    inorr  oi-    Ic-s 
marked   -t'i|Hir  arc   -oon    noti(t'<l,  and   at    tin'    -nine   time   or  a  few  days 
later   tlic  enlartrerncnt    of  the   -pli'en   appear-.       If  -n-pieiun    now  ari-i- 
that    tlie   eon<lition    inav   not   lie  one  of  ordinary   tihiinon-   |inenmonia, 
— at  tlii-  tiinr  inthien/.a-pnennionia  i-  fre(|nently  thont;lit  of, — the  >itna- 
tion    -ooii    lieeoiiie-    clear,   espti'ially    if    at    th(     proper    time,    after   tlie 
diM'ax'   is   of  from    -even   to    nine   day-'  dnration,  eritii'al  deferve-eeiiee, 
or,  ill  i'aet,  aiiv  remi--ion  in  the  -yrnptom-  doe-   not    take    place,  lint  tin- 
pnenmonia  in-tead   remains   -tationary,  and  a  eontinnanee  or  an  incna-e 
in    the    oidar^'crnent    of   the    -|ileen,    ro-cKihe,    ineteori-m,    pea— onp-iike 
st(Mi]-,  and  Itronciiitis  in  the  previon-ly  nninvolviil  |Mirtions  of  the  inni.'s 
make  tln'ir  ap|H'ai~aiiee,      Such   ca-e-,  in   analoiry  with   tiiose  ot'  iiephni- 
tvphoid    pre\  ionslv    tn<iitioned,    have    lieeii    desijj:natcd    pnenmotyphoid. 
iiokitan-kv  '  and  <  Jriessinjrer,-'  -nlispqnently  (ierhardt  ^  and  Kindtleiscli,* 
have  diivi'tcHl  attention  to  c:i-e<  pnrsnini:  this  peculiar  conr-e. 

Strietlv -pe,ikinix,  the  d(-isjnati<in  pnciimot\  phoid  -.honld  he  employed 
onlv  when  the  hacillns  of  l'",lierth  has  Im^mi  .l<'monstrat<'d  a-  the  -ole, 
or  at  least  as  the  principal,  cause.  A-  a  matter  of  fact,  -ucli  caM-s 
po--il)lv  oecnr  ( l.epine  '  and  other^.      See  s(Ktion  on  i'atholoirv ,  |i.   IKi). 

■  Aoc  rit.  '  /."■■    •' 

'  Thiirhifihrhrf  r,,rrrxpn,vlnizl'l..  1ST:,,  N,,.  ll.iuiil  ll.ni.lh.  ,1 .  Khu/rrlinl/,..  1ST4, 
Hil.  ii.,  S.  ']^H.  '  (;iir|i;i:;iii.  I'limi    fti.^s..   Wiirzlnir','.   IHT^i. 

i  Her.  de  ml'l.  1S7S.  iiiui  .Vr.Mv  ,hct .  dr  iniil  .  .liic-.ni.l.  IHKO.  t.  \xviii. 


ii 


I 


I  i 
J 


Ml 


j:.l 


/  )  rii"iii  II  1  /  /; 


m 


Mil 


A  -  \  ct,  liowi  \ ,  I ,  h.it  iniii'li  i-  KiMiwri  i  Miiicniiii'^  llu  in.  l-"iiftliir  liar- 
ii  ii..l.i._:ic  iii\. -iiu;iii..ii  will  lpi-  ric|iiii.c|  In  I'iPi-.  n  i-  .liliniiiK  <li<ii|i<l 
vliili.ri-  -mil  in-i-  iiiiiir,  mill  il'llhv  il",  \v  ii  ||  u  li;il  liiijii.  im  s .  I  l'  it 
Iii'-ImAmi  lliat  |iiii'Uiiii<iii:i  iiia\  I ii  i  :iii-i'il  In  tin-  I \  |il|i lii l-li:ii'illi  .iImiii', 
II  Nwll  linn  lir  iiir(--ar\  Im  i|i  ii  irniiic  \\  li.  i  In  r  l  Inl'c  i-  ali\  -il|i|Mirl  tor 
ll.i'  lliii'l'v,  pn  \  i'iii-l\  iiniilioiirij,  that  a  iliint  iiita-ioli  ul'  tlir  t\|ilii>ii| 
vil'il-  llifiiuirli  till'  aii-]pa--aL'-i-  iiia\  cmiiii-,  ,  ,r  tn  what  lirsj-nc  llic  |iiiril- 
iiiMiiia  i-  |.i  !"■  c  i.ii-iiji  |-i  i|  a-  ijiii-  |i>  an  Mini-iialK  rai'K  ami  faff  |ifiiiiaf\ 
i"cali/.ali"ii  •'!  t'l'  1  i.iita'.:iiiiii  wliiili  |ia-  ;_'aiiiii|  (iitfamr  into  (lir  In  i<|\ 
ll,fiiii;.r|i  ill,'  .  ii-tMiiiafs  [iMiial-.  Ililwici;  -in  h  ,  a-i-  ami  lli'i-r  in  uliirli 
till-  |iiiriiniMiii,  ri.ii-Mlii|alii.n  (uciif-  at  a  iat. f  |.iii.H|  afr  llio-r  in  wliidi, 
allif  an  allaik  nl  aiiiliiilalniy  t\|ilii'lii  liAii-,  a  in  fnilc-crncc  nf  a  fila|i-i' 
-(I-  ill  \\illi  -|priilii'  |iiii'niiinnii'  inrilifati'.ii. 

N\  '■  -liall  in  till-  rnliifi'  |ifiilialp|y  liavc  to  ililU'fi  iilialc  ffnin  |ini'iiiii<>- 
i>|ili"iil    ill   till-   line   iiiiilcii.'-ir   >(ii-i-    ilii.-c   ca-i  -    in  uliiili   (.ili.r   miifn- 

ip|.::mi-iii |iii(iiiiiiiriM-i'i,  ~lri|)iiici.r(i,  ami  -Ia|ili\  Inriicri  —  liki\\i-r   i_'i\i' 

11--    1"  |iliiiu ii'  iiitillfalidii  in  tlir  i  litial  -lai.'^i  ol' t\  |ilioi(l  t'r\i'f.      Sm  li 

<■ litimi-    fi  |ifi-iiit   ifiir  (■iiiii|ilicatiip|i~  diifin;.'-   a    iicfind    in  w  liirli  ci.ni- 

liiiiatiipii--  i-afrly  iif.  aiiij  in  lli<-i'  ca-i-  llic  rjiniral  |iirliifc  i.t'  l\|i|i,.i(| 

liAcf  may  lif  -ifaiiuri  ly  altiiid  ami  at  linn-  r\iii  \\liiill\-  nh-ciiriil.  1 
lia\i-  |ii'f-iiiially  ppli-(i'\  iil  ca-c-  in  wliidi  |iMi'iiiii<>iiia  liiic  tu  |ini  iiimi- 
ippiii  (l(\il.p|Mii  iliiiiiiu-  till.  tl,--(  \\,rU  lit'  an  altaik  of  t\  jilioid  t'r\if, 
wliili'  fip-riphr  ami  -|iliiiir  I  iilafMciniiil  a|i|i(afiil  only  -iili-fijiiciitiv,  anil 
tlnai  III  Ipi  li  I'p  dial   ii|p  tlif  -itnalion. 

Jiiliri^liiiL'  diniial  r\iilfiiri'  in  frLranl  tiitln>c  !ilv|piral  t'ppnns  nl' |p|itiiiiin- 
ty|)liiiiil  liaH  liiiii  I'lifiiinlu-ij  liy  K.  WaL'inf.'  Iml  luitlni-  li.'  imf  lii-  pfcdf- 
I'l-s-iifs  were  alilf.  on  !ii  iininl  nf  \\\,-  .-latr  nf  klmw  It  iIl'i-  at  llif  linir,  tii  iiiakf 
ail  1  liol  PL'ir  iliirifiiilialip.n  .  t  iluir  iiim-.  'I'h  Ih'  .-liaf|>ly  ili.-i  f iiiiiiialiil  fruiii 
the  ^M-^^  tliiis  tar  iiiiiihniiiil  ami  tlii>  lla^  iiipt  al\\a\>  Iptrn  ilmif.  even  until 
"itiiiii    a    frreiii    peri. piI-  ale    lliiPM-    tiiiiii-   pit'  :.'eiiiiiiie    | piieiiianiiia   wliieli,  in 

iiPllMP|llenee  ipt  I'le  111"  I  i'.'ll  il  \  .  ill  I  lie  ^\  lll|  i|c  Plual  ie  .-ellM'.  ipf'  tile  if  t\  |illuili-like 
I'piirse.    have     lieeil    ile-    -iniIppI    jpiiellliiiity  |p|ip  pjp  1.    or.    at    time:*.   tviilipi|p|    jpiiell- 

iii"iii:i.      Tlie    eppiiilili.  p,    |.i-eMiit    i.s   uiiiliiiilileii,'.   iMio   nf  iiillai atiiiii  of  tile 

liniL'-i,  uliieli  |.iii>iii>  a  |iartie\ilarly  iinl'aviiralile  eniirH',  in  e(iii>e<|iipiiet'  nf 
iii'livipiiial  l•i|■el||M^|alM■es.  nr  Ipip'aiiM'  il  eiiii.-iili:te>  niie  of  tlie  iiiaiiilestatioii^ 
ot    one  of  I  he  other  >e\  efc  iiifepl  ipiii-  i  li-.  pfp  111-,  a  II  ion  L'  "  hull  .-e|pt  ieeiiiia,   par- 

tieiilarly  the   ervpipijeii.-iip'  \:iiip|\.  i-  lo  he   ineiiii .1  ahoxeall.       In   aihli- 

lippii  ipp  .-e|ilie  |piieinii.iiiia.  ih.  mixi  .|  iiileeii..ii-  p.l' iiihereu|pp-i-  with  the  |p\oL:enie 
aLTeiil-  that  ha\c  heeii  ri|iealp.ily  iiieiitipiiiepl  lia\e  heeii  eoii>iilereil  a.-  piieii- 
nippty|p|ioiil  iir  lyplioiil-piieiniionia. ' 

Abscess  of  the  lung  I-  eun-iili  n d  an  e\i,  edinudv  fare  i..iiipliea- 
li'iii   111'  typlmid    li\ef.       .\li-ee--es    are    pri.lialiU    eiieipiinlei-eil    im.,-t    fre- 
'  DeiJ.i,-/!.   Ai;-h.  f.  I.r,„     M.  -  .   IM     wxv    i,i;,l  xlii. 

»  S".'  iho  »tllt!-t!','-  ■•!'    K-    \\  :i'_'l:'T. 


N)  1//'/ol/v     I  \/i   /  0I//7 /r  I /70.V.V  •_'•").". 

i|iiiiillv  a-  nicla-tatii'  plufiiiiiicna  a--iiii:ii(.|  wiili  cuiiiiilical  ini;  ^ctii  nil 
DWtiiia  ;  lliiA  al-"  i\(i|iiiMiiall\  oriiir  a-  -ii|iiiU  nl'  luliar,  lilniii'Mi, 
|iiniiiMiiiiia.  Ivmp  ra-i-  (it  tlir  lalirr  variitx  haM-  i-umr  iimli  r  riiv  |Mr- 
~oiial  iili-(Tvalii)n.  A-  llicv  ■Kciir,  likr  tln'  |iiiiiiarv  cli-ia-i  .  <~|>i(iallv 
ill  llir  latrr  -ta;.'!-  m|' i\  [ilinid  l(  vc  i-,  liny  i/wi-  li-r  iiinli  r  iln  iiin-t  laMn-- 
;ililc  idinliliiMi-  In  c(iii-i(|iralili-  rilanlalinii  ut'  cciiix  ali -c  iiicc,  it'  ilicv  dn 
iml  art  a-  llic  laii-c  inr  a  liilal  Ic  riiiiiialinii  nt  tin  ili-ia-c.  \\  it!  Mt 
iliiiil't.  tlic  laltif  i-  iiKiic  liUrly  to  occur  a-  a  i-c~iilt  ol'  ali-cc--  nl'  tlic  liiii^ 
(mIIuvv  iii;_r  i\  plhiid  l('\  cr,  than  it  i-  alter  a  I  )-•!--  Inllnw  iiii;  -implc  liliriiiiiii> 
|iiiciiiiii>iila.  W  lii'tliiT  |iii<'iiiiiiiiiia  dill'  to  tin  1\  |>lioii|-l>acili.i~  iiia\  l>i' 
I'ojluwc'd  iiv  til.'  tiiriiialioii  ot'  an  ali-cc--  lia-  not  \ct  liccii  c-ial)li-iii  il, 
iiut  it  is  ciilii:'lv  |priil)al)ii',  a-  the  l\  |ilioid-iiacillii-  i>  will  know  11  to  lie 
ail    illili'|iciidi  lit    |iyo;_rciiic   aLTiiil. 

Syiii|itoiii~  oi'  pulmonary  infarction,  wliicli  con-i-i,  c—cntialiy 

in  tlir  dc\  f|o|iiiicMt  III'  an  ariltc  alcliialc  consolidation,  \\illi  licinu|it\ -i-, 
I  liavc  oi(-ii'V((l  rc|iiatcdl\ .  It  i~  iiio»t  rrci|ncntly  atti  il'ilalilc  to  tlic 
di'tai  liiiiciit  of  inaiaiitic  tliioinlii  in  tin'  i'ii.dit  -idi  tlic  licait,  1 -|H'ciall\'  , 
in  tlic  ani'icic  and  the  aiiiiciilar  a|>|iendi\.  (  >i  •a-ionalU  ,  it  i~  tiiic,  the 
tlil'oinliiis  i-i  ijciivcd  I'loni  the  |ieri|ihcial  vein-.  In  -tii|>oioii~  patielit.- 
ilil'afctiun  occur-  now  and  airaiii  without  noteworthy  -iiliiective  iiiaiii- 
f'cstation-;  ;  tiii-  i>  innrc  likely  to  he  the  ea-e  -ince  -Itch  patient-  do  nut 
■  e\|(e<'torate  |)i'o|ieil\ .  Mo-t  rrei|nent|v  aeeelcralioii  of  thi  piiUe  and  of 
re-])iratorv  rrei|iienev  are  al-o  oh-crvcd. 

While  inrarctiiin  occurs  in  -otiic  ca-es  without  a  r'hiij  and  without 
clcvalioii  of  teiii|ieratuie,  in  others  it  -ct-  in  with  a  e'lill,  and  snh-c- 
((ileiitly  the  tem|)enitili'e-eurve  -hows  -c|itic  charactcri-lics.  |  have 
oli-ervcd  the  latter  kind  ot"  -yiii|)toiiis  e-|)eeial!\  iliirin;:  cons  alcsceiice. 
riie-c  -\  niploiiis  arc  citlur  the  tir-t    inatiife-tatinn-  ot"  a  |i\eiuie  disorder 

or  are  due  to   ciiiholi   in    tin iir-e  ot'  -iich  a  di-ordcr.  and    tlie-e   ea-es 

aiiiiost  always  |)iii'sue  an  utit'avoralilc  cour-c.  I'liderthe  tim-t  tiivor- 
al)l(' conditions  tlic-e  lesion- arc  l'oll,iw''<l  li\  eirciiin-ciil)cd  ^'antrrene  of 
the  liiiiLr-  with  putrid  plenri-\'  or  even  liv  pneiiniothorax. 

Kml)oli-iu  of  lai'L''!'  Iiraiiclie-  ot'  tlii'  pnliiiouary  arterv.  which  fortu- 
nately i-  rare  as  a  can-e  of  -uddcn  death,  has  lieeii  rcfcrre<l  to  (-co 
Analoim  ). 

Pulmonary  gangrene  appear-  to  ]»■  -omewhat    more  tVe(|ucut 

than  alisces-  and  infarction  in  the  course  ot'  typhoid  t'ever.  Kxcliidiue^ 
the  cases  ot  -eptic  eiiilioli-iu  jp-t  rcfernil  to,  pnlinonat'v  i^uilt'''''!''  occurs 
nio~t  t'rcipieiitiv  as  the  termination  ot'  johar  piiennionia  of  nio-t  diver-c 
oriirin,  espeeiallv  of  tlhriiiou-  piieninonia.  The  condition  lieloni^s  almost 
nnc.xeeDtionallv   amoiiLr   the   coninlications   ot'  the    late    iieriod.   since,  in 


1? 


I 


'  il 


]} 


:^    ^ 


VJ. 


•_'.".•; 


ryrii"ih  nvri:. 


?!l 


\^\ 


nil 


inlditiiili     to     llir     ;irli\it\-     i  if     llic     -|ii'';,l     IiliiTi  i-(>Il:;iii1-III-     riinccl'liril, 

\\c:iknr--  i.r   ilii-    Ill-all    ami    L;iiiiial   iiiia.  iat  i^n    |il..\    a  i  !•  Ii  riiiiiiiiiL;-    .•.:/(■ 

ill     il-    ili\(|M|iin,iil. 

In  1  i\\~v  I  iili-i|-',il  piiiiimnnia  ili-M-raii-  ■•rriir  in  llir  .TiiHinr  nt" 
oiin]iiii':iliiiL'  lil'i'iniiu-  |.iii  iiiiinnia.  I'lirtiiiialily  mr  llir  patii  iil,  1  In-  li-iup 
rupliinMl  iiiln  llii    |,|(iiral  iavil\.  aii'l  ili^-  >r.|Ur.-i  nim  u:k,-  ilischavLicil  iiilo  ii. 

A    ITMTlidll   n|'    llir     liU-  nialillM    Mir   In      wl'llal,     llll-  coliMillli'llt    |iUlrii|   ciiiiiy- 

iiiia.  iMLTlhi  i-  uitli  llir  :jaiiL'riiiiiii>  |.iiriiiiii>  nt  hiULr.  iiii'l  m'  ti>  I'riiiL'  alHUit 
a  |itiaiiaiuiil  i  iin-. 

'I'lir  'a-i-  I'l'  |inliii"iiar\  naiiiri'i'Hc  ir-iiiliiiu  iVmn  llii'  a-|i!i-:it!iiii  n|' 
(|ic.iiM|"i-,  .1  intirtit.ii-  mall  rial.  Ji  ii\c<l  r-|iiviall\  liniii  tin-  iiininli,  the 
nan-,    .iiiil    iIh'    |iliai\ii\.    arc   al-M    im|">rlaiil.        !ii     llii-    rniincciinii   a 

-Uirial     '■'■/'    i-     |ila\  ill.  arC'liJillL;'    I"    ln\    i  \|irrii'llrr.    Ii\     tllr    imilv    -ll|irr- 

tiii.il  and  ai-"  Ia  tlir  inni'r  |iri  .I'l  mml  nlnial  i\  r  ll.nn  nf  |inriilinl  imi- 
»iHiti-.  and  r-|MTiall\  li\  t lir  la-i  -  nf  lai-\  nigral  nli-cialii m  and  |m  ricliim- 
<lriti>.'  In  d>i|il\  -tii|inr'.n-  |ialirnl-  -ndi  •■■'iidilioii-  rrinaiii  (•niiccali'd 
tVi'in  llir  |ili\-ii-ian  -m  Iniii;  a-  llir  lr-i'iii-  aiv  -till  -mall,  and  iircninc 
di-linrl  "uIn-  al'lir  tlir\  liasc  allaim-d  a  irrlain  iMriil.  In  addilii'ii  to 
tile  int'rriii.ii-  inatciial-  iiHnli"nrd.  a-|iiratii 'li  nt'  paftirli--  ut'  liHid  i-  al-o 
ocra-iimallv  tlir  caii-r  ol' |ininiiiwiiia  \\itli  ->  ruiidary  nani'i'iiir.  It  >h(iiil(l 
nut  lie  t'lU'Lotlin  in  llii-  cnniK  rlion  lliat  a-|iiratii'ii  i>t'  |iaftirlr-  lAcn  "f 
('. iii-idrralilr  -i/v  liv  |)r  .ti.iindl_\  -iii|ii.riin-  [lat icnt-  iicid  nut  j;i\ c  I'ix' at 
(iiii-c  til  -|)ccial  -\  in|it'im-. 

I  liavf  (iliMivi  i  liaiiLTi-riH'  lit'  aliim-i  ilir  entire  Inwcr  lnlie  nf  the  rifrht 
liniL'  ill  a  NniniL'  man.  lIu'  caii.-c  I'm-  wliirh  «as  ili>r|(isccl  unly  ii|Hin  ]Mi.--t- 
ninrtem  cxaminatinii  l'\-  llir  ili.-cii\  i-ry  nl  a  (liiii-  nt'  ilrr(ini|Mi.sf(l  meat 
iinpaiied  in  a  larL'i-  liioiirliu>.  .\s  -nli>e.|iiciilly  apiuand.  tlie  |ialieiit  iiad 
rc-ceivrd  inial  -nrre|'lili"ii>l\  al  the  lui-lil  i.f  the  telirilc  |M'i-i(iil.  w  hile  lie 
la\  in  a  stunmou-  -lati  .  and  tin-  lime  ulieii  a  purlinii  el'  ihi.-  ua.-  a.^pinitt'd 
•.va>  ii'il  even  iu'leil  l.v  the  iieiLflili'irin.r  |lalielll^. 

I,iel)erimi-ter  lia-  i'i-er\id  ea-i'-  ct'  i  '  leii-ive  L''ani:i'<'iii'  "•'  the   iimjr 
witlmiit    anteeedenl    inllaininalinn  nl'  tiie  urpin   (ir  a-|ii'-alioii  ut'  liireiirn 
Imdie-,  and    he    ha-   atlrilmted    the   cunditi    ii  |i    the  niiil>nal    >-e\-el-it\   ot 
the   u;eneral    di-tiirhanee  nl'  nntriliiHi.       In  \ie\viit'tlie    larm'  ex|ierieiie{' 

(it'  llli-  iili-er\er.  the-i'  ea-e-  .  1  ri  ■  e-|ieeia|ly  IH  ileUi  Hi  ll\  .  I  ha\e,  tiill!!- 
Ilali  1\.   n.it    a-   \  el   eneolllili  red   -llell  ea-e-. 

II  i-  |ieiiiliar  ihal  MunliiMHi  enn-i.lered  -anirreiie  nftlie  hnii:  an  exlreiiiely 
rare  e.,in|ilieati.'n  111' ivplmid  t'e\er.      |le-a\\   Inn    1  irr  'J  ia^e>  « liieh  t'niliiwcd 

I iiMiiiniain  the  emir-c' nl' l\  plieiil  t'ever,      (  )ii  1  lie  el  lier  hand,  l.ieliermei.-lcr 

enruUMlen'd  L'-aiiL'reiie  in  i  t  ameiiLT  '-•!"  t'al.al  ca-e-.  il  is  (|iiile  remarkaliio 
that  1*  el'  llis  ea.-e.-  eerlirred  in  llie  rnur-e  el'  lliree  limiilli-,  ilurillL''  "liieh 
the  iidsiiital  ua-  L're.-ilU   ii\  erereu.led  ami  il  "a-  im|His.-iliie  In  pnivide  -iiila- 

,...,.  ul-M   Cur-rliiuunn.      'Da-   I'L.  Uli.  !■.  r.      /.„  „. -   II.i,„li,„ch  ,/,  U,i,.  Mel., 

lUl.  ii.,  :;.  .\ull. 


li:;  1 


SYMI'I'iMS   A.\l>   cnMrt  KAIIoys. 


257 


lile  livL'ifiiic  cnihliliuiis.  ( irifssiiijrt'r  liasnliMTvcu  L;;iii'_'r(iic  in  7  cit'  llScascM 
exarniiif'l  |"'.-l  incrliiii.  liiiiiv  Loips'u- >lali.-ti(>  il  i>  i-iM-niilid  in  1  It  inrtaiicf.-' 
ill  ■J"_'>i  aiiliiii>ir>. 

'I'liat  tlic  In  i|iitiiiy  ut'  tlic  pleurisy  i-  \aii(iii-i\  -lat<<l  hy  (litrticiit 
i)t)-crvrr-  i-  |)i(ilial)lv  (1(  iicniliiit  ii|Miii  ililVcuiii  iiiici'|ir(tatiiiii>  ut'  tin- 
tffiii.  It'  v\rv\  riiciirii-crilinl  |il(iiiiiii'  t'liclinii,  overy  til>riii()U> ',li|>.»^it 
ii|«m  tlir  |ili  Ilia  In  lax-  nf  luliar  and  Iwimlar  i>!itiini(iiiiu  or  (itlicT  t'ocai 
(li-<a-r  (if  ilii'  liini:.  i-  incliicliHl  in  tlii-  citcL^ory,  tlicii  |ilriii-isy  Ls  alnmst 
as  t'i(i|ii(nt  a  ili-«a-c  a-  llic  atViHticiii~  of  tiiu  jiiilnioiiary  parcneliyniu 
it-elf.  II'.  liipwiM  r,  a-  a|iiMar-  to  I"'  limn'  |)nicti«il,  jn'iiii'i])ally  tlio.se 
ca-is  arc  I^rjil  in  mind  liiat  .i|i|Mar  more  or  lc>-  iiidcpclidciitly,  psjk'- 
I'iallv  tliosc  attend  (I  with    tlie   de\  e|M|Hiieiit   of  iiiodenitc  or   lari;e  etfll- 

>iun>,  tlieii  llie  < litioii  is  a  rar< euiTeiiee.      W'lieii  it  oceiirs  at  all,  it 

is  a  liianifestatioii  ot'  tlie  late  t'ehriie  pi'liod  or  of  eoii\aleseelice.  I  have 
exce|(tionallv  eiieoiinleied  |ileiiri>y  dining;  tlie  first  week  which  was  siieh 
a  ])romiiieiit  featnre  ot'  the  ease  that  the  (lesi<riiatioii  jileiirotyphoid 
mi^ht  lie  eiiiiiloved  in  the  same  way  that  French  investigators'  have 
Used   ])nenmotv]ilioid  and   nr]ilivoty|ilioid. 

In  a  mimlier  ot'  eases  the  typhoid-liaeillns  ha-  been  obtained  in  pure 
culture  t'roiii  the  st  .-ous  or  purulent  pleuritic  etl'u>ioii,  and  its  primary 
etinlogic  siiriiitieanee  in  a  uuiiilier  of  these  eases  seems  tliirly  well  estab- 
HsIukI  (see  section  on  I'atholoj'-v ).  J'leiirisy  in  typhoid,  just  asunder 
other  (•ireumstaiic<>s,  is  prohahl^  generally  secondary  to  atf'ections  of  the 
lungs  or  of  ot  ,er  contiguous  stnietiires.  Cases  of  empyema  csjK'cially 
'  have  heeii  able  to  tm'c  to  antecedent  di-ease  of  the  lung.  A  number 
of  heiuorrhagic  etfiisions  that  !  have  encouutereil  prove<l  to  be  tuber- 
culous. Certain  serous  etl'usions  |)os^il)ly  have  a  more  independent 
origin  ;  these,  however,  in  my  experience,  rarely  liecome  large,  and  tliero- 
fore  but  exce|itioiially  demand  the  performaiu -•  of  thoracoi'cntesis.  If 
direct  interventi<in  is  not  undertaken,  tiiesc  aie  usually  of  longer  dura- 
tion in  cases  of  tyjihoid  t'ever  than  when  there  are  coniplic^itions  of 
other  di-eases.  Xow  and  again,  it  is  true,  ]ileuritie  cil'usions  of  consid- 
erable si/e  disap|iear  i-i|iidly  witliout  especial  interference.  Only  re<'cntlv 
I  observed  in  a  student  sutVeriiig  from  tvphoid  tevcr  a  large  left-sided, 
serolibrinous  etl'iisioii,  with  coii>iderable  di-placeincnt  of  adjacent  orgins, 
whrich,  nevertheh'^s,  iinderweiit  absorption  in  the  course  of  two  weeks.- 

•  Li'i'i'i'i'liT'  ami  Talaiiioii.  K'mli  •'"'..  issl.  Ciriiiniri  SiV.  Dif  r\r,fa''hrn  LmHint- 
kri'.nktiiitt  I,,    <ifriiiaii    tniii-iati-i.)  *^alntin.n.       Cliarriii   antl    lioixcr.    Nor.    }in'ii.   lirn 

/"'./).,  April,  IS'.il.      KiTiift,  //<///.,  :>Ia>,  I'^'.il. 

'  It  iiinv  111'  cmisiiifTrd  ii')tPWiirtli\   lliat  in   llii:-  ra-i'   tlic  fliiiil  nlrtaiiiid  with  tlic 
''\|iliinitory  ni'i'iili'  ixhiliitcd  t\  rharactcri-tir  aL'L'liiliiialiiiL:  'Iti'  t  ii|m'1i  lioiiillnn-cultures 
I'f  tTiihi'ici-lmcilli  ill  tlu;  saino  Ut'i;rcc  m  Uif  lil", .J-itcruMi  cil'  tin;  imtii'iit. 
17 


IIL 


•; 

4 

i 

\ 

\ 

■ 

i 

^i 

868 


TVI'Iloin   FKVER. 


p; 


The  i.ii(i;nosis  of  sciiiiis  cxiidatos  in  tlic  coiir.-i'  of  typhoid  fever  is, 
aceonliiifr  to  my  experienee  not  |);irticiil:irly  imtiivonihie.  Tliat  it  lias 
been  <-on>i(leriHl  so  ii|hpii  tiie  autliority  of  Louis  is  <iue  to  tiie  faet  tliat 
the  iiuiiviiliiai  varieties  have  not  i)een  a(lei|nately  ditVereiitiateil.  Xatu- 
rallv,  jdcnrisy  is  ot'  tlir  ;;nivtT  sij;iiitieanec  if  iiiiriileiit,  heiiiorrliagie,  or 
even  putrid  etVusions  are  ineiudcil  under  that  Icriii. 

Pneumothorax  is  an  <xtreniely  i-are  eoniplication  of  typlioid  fever, 
and  i^  to  i)e  considered  Mierel\  as  an  aeeiilcnial  (M-currenee,  jrenentlly  in 
ooiijunetion  witii  disease-loei  in  the  hniirs,  puhnonary  aiiseess,  ])ulnionary 
gjlllfri'ene,  etc. 

Pulmonary  tuberculosis  hears  various  ini|mrtant  rehitions  to 
tyjihoid  fever  as  a  eonipHcation  and  a  siypiel.  Kveii  ejiriier  writer-  wen- 
aware  of  tliis.  Coiilrarv  to  tii''  opinion  of  thc-e  early  writers,  however, 
the  view  is  p'nerdiy  iield  at  thr  present  day  that  when  tiihen'uh.us 
iiroeesses  ajipear  in  tiie  setjUeiiee  ot"  txpiioiil  t'e\  er,  tiie  condition  is  not 
<hie  to  an  intercurrent  disease,  Kill  ahiios'.  always  is  tiie  first  niain'fes- 
tation,  or  represents  the  proirres-ion,  of  an  earlier  process  wiiicii  iiad 
liitiieHo  been   more  or  less  concealed. 

The  apiM'iiranee  of  tui)crculosis  is  contined  almost  exclusively  to  the 
la»ei'  |)eriod  of  typhoid  fever.  Kven  in  the  latter  half  of  the  febrile 
j)eriod  it  is  less  eotiimoii  than  diiriiiir  convale-cenep,  and  in  some  ea-es 
the  svm|itoins  hecoine  distimt  only  after  the  patients  liave  left  their 
IrhIs  and  are  apjiareiitly  eonvalescent.  Cases  of  the  latter  ehanieter 
led  earlier  writers  to  helieve  that  typhoid  fever  miLdit  tenninafe  in 
pulnionarv  tuhereulosis  iiy  the  diriK't  caseation  of  intiammatory  foci 
develoiH-d   diirinjr   its   course. 

Tuheri'Uio-is  occur-  in  various  forms  in  the  course  of  ty])lioid  fe\er. 
I  lia''c  observed  iniiiarv  tuberculosis  as  a  conipliiation  only  with  rela- 
tive niritv,  and  then  c-pecially  ilurinj:  the  last  part  of  the  febrile  ])eri(Kl 
or  the  first  |)ai1  of  convalescence.  I'ntler  siii'li  circuin-taiKcs  there  is 
danirer  of  eonfu-in<r  tlii-  condition  with  intercurrent  cerebrospinal  men- 
iiiiritis,  which,  as  e\|ierience  has  -howii,  u'ay  M-cur  at  llii-  linie  (sec 
Nervous  Sv-tem).  NotinL'  the  loii-iderable  accelenition  of  re-pii-alory 
fnipieiicv  whicii  attend-  the  nervou-  nianiie-talion.  careful  ob-ervation 
of  the  chauL^es  in  the  plivsical  conditions  of  the  hiiiL'-  and  examina- 
tion of  the  eve-irrounii-  will  help  to  clear  up  the  sitiiati<iii.  Positive 
results  from  examiualion  of  the  -putinii  umler  such  eireuni-tanees  are 
less  to  be  expected  than  when  miliary  tuberculo-i-  (M'cur-  iiidepeiidently. 
On  the  other  liaml,  ])o-itive  re-ults  are  more  to  he  expeet<'d  in  the 
extremelv  rare  c.isc-  of  mixeil  iiifetjons  ot'  tihrinou-  |>n<^umouia  and 
tuberculosis    in  cases  of  tvphoid  fevei',  which  exhibit  iiotliine:  di-tinctivc 


i?MS , 


SYMI'TOMS  AM)  VOMl'I.lV.lTIOSS. 


2->9 


from  tlie  iiliysic;il-<liajrnostic  stjtn<l]K)int.  In  1  siu-li  cjlxo  I  was  iil)lc> 
to  (Icmoiistnitc  tiil)ercU'-l):irilli  in  iiKxlcrate  iiiiiiiIkt  in  the  sputnni,  in 
addition  to  tlie  Friinkt'l-W'ciclisi'lbauni  diplooK-ci.  Exccptionallv,  I 
liavc  ol)si'rv(.'d  the  tiilxTculoiis  priK-i'ss  to  a|)|>oai'  in  the  t'onn  of  acute 
or  siil)acnte  ])rril)roncliitis.      A  case  of  tliis   kind  under  inv  ohservation 

betraii   as  t'ariy  as  the  third   week  ;   '1  otiier: and  this  appears  to  ho 

the  more  usual — ihirinj;  eoiivaieseenee.  As  dire<'t  examination  of  the 
hinirs  under  such  eirenmstanees,  particularly  at  the  hefrinninir,  vields 
only  uncertain  residts,  such  eases  may  Ik^  the  sdurce  tor  various  errors, 
es|M^MaIly  the  asMunption  of  simjjle  riMTudeseenccs  or  relapses.  Such 
patients  also  ex|)eetonite  hut  little,  if  at  all,  and  the  sputum,  in  niv 
ex|M'rience,  rarely  contains  hacilli.  Of  diay:iio>tic  im|M)rtance  on  the  one 
liand  arc  the  in<'rcas(!  and  persistence  of  the  fever,  without  onlarpMnetit 
of  the  spk'cti  or  presence  of  fresh  rostnilic,  and,  on  the  other  liand,  I'on- 
siderahle  rapid  in<  rease  and  extension  of  the  hronchitie  syni|)toms,  with 
pulmonary  emphysema,  subjective  and  olijective  dyspnea,  cyanosis,  and 
sweats. 

(^uite  rare  al-o,  but  imjiortant  on  account  of  the  daiifjrcr  of  confu- 
sion witii  other  varieties  of  loi)ar  |)neiMnonia  oci  urriny:  in  die  eoui-se  of 
ty|ihoid  fever,  is  acute  tuben  ulous  infdtraticui  of  considcnible  |)ortiolis 
of  tlie  iinijrs,  e-|K'eially  of  the  lower  lobes.  This  condition  mav  set  in 
with  a  chill,  pain  in  the  side,  severe  couf;h,  and  blood-tin<re<l  sputum, 
just  as  do  other  forms  of  pneumonia.  Nevertheless,  the  jHTsistcnee  of 
the  tever  and  the  imiK-rfw't  resolution  will  soon  arouse  suspicion,  which 
iHM'omes  converte<l  into  sid  certainty  by  the  denionstr.tion  of  elastic 
fibers  and  tui)crcli'-bacilli  in  the  abiuidant  mucopurulent  sputum,  and 
probably  also  by  tlic  phy.-.ical  sijrns  of  breakin>r  <lown  of  the  pulmonary 
tissue. 

The  onset,  the  first  symptoms,  and  the  course  of  .-nbacute  or  chronic 
tul)erculosis  of  the  ordinary  kind  eoni])licatinir  tyi»lioid  fever  are  ditfer- 
ont  in  every  individual  case,  and  are  to  be  valued  in  dia^-nosis  and 
profrnosis  aceordini.dy.  l-'ortunately,  the  assiK'iatioii  is  bv  no  means 
trecpicnt,  and  the  outl(K)k  for  ehcckintr  the  tuberculous  |)r(K'ess  is,  in 
niy  exiK'rieuce,   not   so  irloomy  ii.s   some  clinicians  believe. 

NERVOUS  SYSTEM  AND  ORGANS  OF  SPEQAL  SENSE. 
Tyi>hoid  fever  is,  not  without  «iusc,  known  |)opnlarly  iiss  nervous 
fever.  The  physician  must  admit  that  this  desijrnation  is  appropriate 
in  view  of  the  prominent  nervous  symptoms  of  the  <lisease.  In  fact,  the 
liisturliance-  on  the  part  of  the  nervous  system  in  cases  of  tvphoid  fcvr 
are  es|K'cially  fre(iuent  and  varied.      They  cK-eur  from  the  (airiiest  [htLkI 


I! 


•■;t: 


\ 

.  ! 


•ifio 


TYrilnlh  I  i:vi:i!. 


tlipillviliiillt  .il!  .-I:Vi.''-,  -iliil  tlil'iali'll  till-  |iatiihl  I'ai  iiiln  ninvalocriut'. 
l'",\(ii  ill  llic  |nrii'il  (if  iiiciiliali'in  ami  in  llic  initial  -laLTi'  iirrv<iii-  >viii|i- 
tiiiii-  iiri'  marl  cd.  'I'lioc  iiicliidc  j^ciicral  iiialai-r,  niciilal  ilcpn- .idii, 
draiiiriiiu:'  -ni-alii'ii^  and  iiminLr  |'ain-  in  the  I'Micrnilic^  in  llic  cinir-r  nl' 
tlic  larLT  luTNi-irunk.-,  -acral  pain,  \frlii;(i,  ruaiiiiL;  in  llii'  car-,  and 
licadaclic. 

Ilcadaclic  is  jimlialily  mic  of  tlic  must  cun-lant  -\  injituiiis  of  the 
initial  ipcrind — tar  iiinrc  (dii-tant  lliaii  tlic  sural  pain.  Jt  i-  ai  tiint- 
ri'lcrri'd  in  the  iurilicad  ur  to  tin'  ocripnl,  Ic-^  cominonK  to  one  -idc  .>{' 
the  licad.  At  oilnr  tinii-  it  fxliiliit-  an  intriiM'  .-taliliini:.  liorinjr  cliar- 
artcr.  At  still  otliir  tiiiic- — and  llii>  i-  true  oi'  tlu>  inajoritN-  o|'  -ascs 
—  it  i~  di--crilic<l  as  a  dull.  Inavv  iirr-~iirc,  or  is  like  a  liaiid  tifd  alioiit 
till'  head.  'Iriic  miirali^ii'  pain-  a-  an  initial  -xiiiploni  of  tvjilioid  fever 
:n>  Worthy  of  iniiitioii,  e-peciallv  jiain>  in  tlie  di-trilintioii  of  tliu  .-iijira- 
orbital,  infra-orliital,  and  oecipilal  nerves,'  altlioiigli  in  mv  experiellee 
till  V  are  rpiite  rare. 

ruw.ird  tile  (lid  of  tile  tlr-t  or  at  tile  Ixj^iiinilij^  of  tlie  >econd  week, 
in  ea~es  of  iiiodi mte  or  ,-evere  eoiir-e,  tile  eom|ilaiiit  of  lieadaelie  and 
the  I'eiiiainiiiLT  >ill)|tH'tive  uerxcpii-  svni|itolils  si-eiH'riillv  le— eii.  'ilie 
patient,  now  lieeoniint.''  stupid,  is  no  loiiLn'r  eapalile  of  appreeiatintr  his 
londition,  and  hi-  -tateiiieiits  eamiot  he  ri]ie<l  upon.  It  i-  even  L.treiitlv 
ad\  i-alile,  when  a  typhoid  patient  still  e(im|)lain-  iwf  headaelie  or  V(  rtipi 
at  the  heijriit  or  toward  the  end  of  the  fehrile  period,  or  iie<_riii>  to  make 
new  comiilaiiits  of  hi-.idaehe  at  tliat  time,  that  attention  lie  direeti  d  to 
foinplieations,   e-pe<ially    iiieninixitis  and     ither   intracranial    alterations. 

In  the  tir-t  -tatre  ot"  the  di-ca-e,  almost  coinciileiitly  with  the  coin- 
])!aiiit  of  headache,  there  is  p'lienillv  complaint  ol  sleeple-sne-s  .tIso. 
This  Imh'oiiic-  less  proiioiince<l  with  increasiiii:  stupor.  .N'atiirallv,  a 
sliar])  distinction  must  alwavs  he  made  hetwceii  -ojHir  and  ^leeji  in  a 
sick  person.  ll.cry  experienced  clinician  know-  that  a  -tnpid  |iatient 
may  actually  sle<'p  or  niav  he  skH'jilcss.  On  I'nitlier  examination  it  niav 
lie  found  t!iat  the  sleeple-snes-,  althouirli  the  patient  iiiav  no  loiicrer  com- 
plain of  it,  per-i-ts  in  varyiiiL'  deirre<'  tliroiij.dioiit  the  entire  felirilc  stap'. 
The  majority  <  '  patients  -leep.  it  at  all,  for  only  short  |Hri(Kis,  with 
fre<|neiit  iiitcl  rnption-.  The  relatively  larly  ocenrrcnee  of  profonnd, 
lontr   -lecp    is   a    fiivoralile    -iirn. 

Toward  the  cihI  of  the  fir-t  week  tlii'  -e\  ere  and  the  nioderatelv 
soverc  case-  alino-t  rci:ii!arlv  hci^in  to  exhiliit  that  condition  of  the 
nervous  sy.-tcm  which  i-  dc-iLMiated  as  the  actual  tyjilioidal  state;  which 
is  attend(Ki  with  ohtimdin^''  oi'  con-cioiisne-s  ami   dulling  of  the  special 

'  Sff  ().   i;..frTibm.'li.  /V»^v  /(,  Arc/i.   f.  Urn.   M.,/..   I'M.  xvii. 


sYMI'TdMS  ASn   CnMl'I.ICtri'iys. 


2t;i 


<('n-('~.  'Ill''  <<'m]>l:uMl-  Ii'>-;('n  ifni'luMlly,  tlw  intiTr-t  of  tlw  ]>atii'iit  in 
lii>  -iiiToiiniliiiir-  iliiniiiislio,  and  the  doirc  tor  I'immI  and  drink  licconics 
imiirrc-.-iv  rl\-  Ics-.  Tiic  patient  lies  in  an  apatlu'tic  >talc  in  ii  rclaxctl 
diiisd  dci-iihitn-,  l)nt  still  reacts  -Injrjiisldy  tn  lond  speakinj,',  to  <|ne.-- 
tiiiii-,  anil  Ik  active  >ens(iiy  impi-e.-.-iuns.  His  statements  are  still  fairly 
rational,  hnt  even  siinjlit  deniand>  n|K)ii  mental  activity  are  siMtKlily 
fullowed  l)v  faliiTue.  Alter  niakinj;  brief  replies,  lie  relapses  into  his 
stU|H(rons  condition,  in  wliicli  lie  is  likely  to  l)e  annoyed  by  dream-like 
liailiicinations,  wliicli  constantly  reapjK'ar  as  s(K)n  as  the  eyes  are  closed, 
or  even  durini;:  the  half-wakinj.'  -late. 

With  the  |)rojrrc-s  of  the  disease,  jrcnerally  at  the  liej^imiini:  or  the 
middle  of  the  second  week,  in  seveie  crises  or  in  irritable  individuals 
earlier,  the  dream-like  hallncinations  become  tninstormed  towaril  even- 
in';  and  durin<j  the  nijrht  into  aetiial  delirium.  This  is  ^'enerally  not 
violent  and  ajrsiressive  at  tirst,  but  the  ])atients  rather  work  and  talk 
aimlessly  in  a  (piiet  manner  concerning  matti'rs  relat<'d  to  their  usual 
pursuits  and  experiences,  bein^  influenced  immediately  and  markiKJly 
by  auditory,  visual,  iiul  -ensory  impressions.  At  times  the  hallucina- 
tions are  of  an  alarininix  nature.  Some  patients  complain  of  iiijfhtmare- 
like  conditions,  while  others  cannot  <ret  rid  of  ])eculiar  hallucinations 
with  rcf^.m!  to  oM'tain  parts  of  the  bo<ly.  They  have  an  impressiou 
that  the  head  or  entire  members  are  shrniiken  or  have  disa])j)eare<l,  or, 
on  the  contr.iry,  liav(>  f^rown  to  enormous  si/e  anil  then  have  become 
moderate   in   size. 

Sime  ])atients  exhibit  a  tendeiKy  to  jr<'t  out  of  bed.  I'nder  such 
circumstances  tluy  rarely  injure  thei'.iselves  or  others.  Wilil,  ilangerous 
delirium,  with  threats  ajrainst  attendants,  attempts  at  flijrht.  etc.,  siu'h 
as  are  (|uite  commonly  observed  in  eases  of  typhus  t'ever  and  variola, 
are  very  nuich  le-^  fre(|uenl  in  cases  ol'  ty|)hoid  fever.  In  drinkers  the 
mental  disturbance  i;enerally  reseiiiiiles  that  seen  in  alcoholic  delirium. 
True  delirium  tremens,  such  as  almost  always  occurs  when  hard  drinkers 
are  attacked  with  the  other  severe  infectious  diseases,  as,  for  in-tance, 
fibrinous  pneumonia  and  erysipelas,  and  which  sets  in  with  ra|)id  eleva- 
tion of  temperature,  occurs  with  relative  rarity  in  ty|)l;oid  fever.  At 
the  middle  or  eiiil  of  the  second  week  tiie  delirium,  which  at  Hrst  was 
rtoticcable  only  toward  eveniufj  or  during'  the  niirlit,  bej^ins  to  persist 
also  during  the  day.  'I"he  patients  can  still  at  this  time  be  awakened  at 
times,  and  tiuir  attention  attiacti^l,  and  tempor;irily  even  be  convinced 
of  tiie  <xroundlessne-s  of  their  excitement.  Sion,  however,  the  abnor- 
mal delusions  and  hallucinations  l;ecomc  more  and  more  ♦ixc<l  and  >n- 
scioiisne>s  more  obscure  ;  and  the  ])atients  enter  upon  a  state  in  which 


ii 


i 


;>?^^ 


./v^^"'- 


262 


rvriKiin  n:vi:R. 


h.-  .:)■■■. 


ryr-- 


ir 


thcv  take  ikp  iioticc  nt'  their  -tirrimii(liiij.'->,  and  arc  liay  and  nijrlit  in  a 
drcainv  >tat(',  uncnri.-cinns  ut'  tlicir  cnnditinn.  'I"ln'  t'cattins  arc  rcla.\f<l, 
(■xj)r('>isi(inl('>s,  even  »(inic\vliat  drawn  ;  tlic  ( yc>  arc  wlmlly  <ir  lialt'-npcn, 
.-tare  dircctlv  fiirward,  and  arc  mi>  loiip'r  fixed  i>n  any  dctinitc  (ilijcct. 
Tile  |)aticnt<  innrnnn-  and  arc  (|nieliy  rc-tic-.-,  l)nt  iicccinic  niorc  ai'tivcly 
so  toward  evening'  and  niiriit.  In  nnconipliiated  ri-cs  wliicii  ar<' not 
(it'extrcnic  >cveritv  tliis  cundition  pcr-i-ls  into  tlic  tiiird  week,  and  even 
to  tlic  end  of  tliis  week,  tiien,  wit'i  tlic  Ix^innin;;  ni'  <'onvalcsccncc, 
iuidcrjr"in>;'  L'radiial  iinprnvcincnt.  'Ilic  jjatient-  now  Iwcuinc  (piictcr, 
and  ajT'iin  at  times  eoiisiidii^  ;  tiiey  ln'^dn  tii  slccj),  and  wifli  a  rcdueti<iii 
lit'  tlic  tcin|)cratnrc  to  tlic  iiorinal  or  Im'Iow,  often  even  dui'inj:  the  sta^'e 
of  »t<'c|i  curve-,  they  hccoinc  coiniiicti'ly  rational,  except  dnrinir  >lccp, 
t'spcciallv  at  nitrht,  when  dream-  occur  that  are  t'orpitteii  with  ditlicully. 
It  can  rcadilv  he  imder-t<Mid  that  the  di-turliaiiccs  aliove  de-cril)e<l 
(•xhiiiit  the  nio-t  divcr-e  variations  in  accordance  with  the  M'Vcrity 
ot'  the  attack,  and  especially  in  accordance  with  the  temperament  of 
the  |)aticnt.  Irritahlc  j"  rson-,  children,  women,  and  delicately  con- 
stituted men  naturally  exhihit  niarke(i  di-tnrhance  of  conM-iousiicss, 
when  those  of  stroni.r'  ucrves  an'  wholly  nnart'ectcd.  In  extremely 
severe  cases,  however,  the  most  roltu-1  indi\  iduals  may  enter,  cv<ii 
durinjj:  the  tirst  davs,  into  a  state  of  dclirinm,  which  sinui,  occasionally 
as  carh-  as  the  lieirinniiii^  or  the  middle  of  the  >eeoiid  week,  passes  into 
deei)  -o|Mir  and  into  coma.  Such  patients  exhihit  the  apiwaranee  of 
ino-t  profound  intoxication,  with  paralytic  i-claxation  of  the  iiitirc  hody 
— an  o|M'n  month  with  dependent  jaw  and  dry,  cncrustc<I  mucous  niem- 
hiime  oi'  lips,  toii^'iie.  and  month,  and  lahored,  stertorous  hrcatliinj;. 
'J'liev  I'aniiot  he  complctelv  awakenc<l,  an<l  they  can  only  at  times,  and 
then  l>v  a<'tivc  interference,  he  induced  to  make  traii>itory,  indistinct 
statements.  Kveii  the  swallowing  rcHcx  can  he  elicited  only  with 
ditlicnltv.  The  urine  and  the  stools  are  ^rcncrally  voided  in  bed.  'I'his 
condition  niav,  in  severe  ca-c-.  continue  'hroujrhout  the  third  week,  and 
it  niav  jHTsis'  even  loiiirer,  under  which  circum-tances  it  is  especially 
to  he  mcntio.,  d  that  the  jrraxii,'  ot'the  jreueral  condition  i>  hy  no  means 
coiistantlv  attended  with  corre>|Hi,idinir  clevjition  of  temperature.  On 
the  contrarv,  remarkahly  low  fem|><'raturc  with  a  curve  oi  most  irregular 
course  is  at  times  found  in  assiH'iation  with  a  most  serious  and  most 
alarmiiifi  pncral   condition. 

With  the  more  profound  conditions  ot'  -tup<ir,  jiecnliar  motor  mani- 
festations of  most  varie<l  character  and  >c\ciil\,  I'rom  thi'  simplest 
tremor  to  spasimxlic  twitciiinjrs  and  eonviil-ions,  arc  also  (piitc  commonly 
ass(«'iated.      This  ({(«.-  not    imply  that  such    motor  disturbances  do  not 


.-it--'v; 


syMI'TOMS  AM)   ((tMPI.WATlOSS. 


2(;;5 


uIm)  (K'ctir  ill  ca-K's  ot'  nnxlcnitc  and  iniltl  cuurx'.  T1i«n  art-  iiuicly 
mure  f'riHiiiciit  ami  nunc  iirniKHinccd  in  tlic  sfvcrc  ca.-cs,  lint  ilicy  vary 
with  rcpinl  to  tluir  clianuUT,  diiratiun,  and  extent,  in  aeeurdanee  with 
tlie   individual   irritaiiiiity. 

Siiii|)le  treiiKir  iMcurs  in  deliilitated,  irritai)le  iHi-sdii-  (|iiite  eoinmonly 
as  earlv  ;is  the  initial  stajre.  'riii>  is  the  ea.-e  also  in  mure  mhiist  aleo- 
hdlic  individiiais.  More  inteii-e  motor  di>tnri)anees  jrcucnilly  a|i|)ear  as 
traii>itorv  maiiil'e>tatioiis  in  the  later  tehrile  ,-taL'e  in  tiie  li^diler  and 
moderate  ea>e>.  'I'liev  cK-eiir  early  and  |ier-i-teiilly  aimo.-t  solely  in  the 
severe  ease>,  and,  as  a  result,  ae(|nire  a  deji:ree  of  |)row:ii(i-tii'  >i>riiitieanee 
not  to  he  nndeirated.  Anioiii;  tlie.-e  iiioroeMre  di>tnrl)anee>  piekinjj;  at 
the  eiothinir  (Hn.titatioii)  i~  tiiM  to  he  mentioned,  -  it  prohahly  is  the 
iiiil(le>t  and  lea>l  -i^-nilieaiit  t'rom  tiie  |(ro^r,ic,vtie  poini  of  view.  The 
so]Kirose  patient,  lyin<:  <|uietly,  inoviii;:  tiie  lips  miinierniptiMlly,  iiinr- 
miiriii;,'  iiieoiiereiitlv,  pulls  eon-tantly  with  tremnloiis  hands  at  the 
elothin^  and  hed-coverin^''.  In  tint,  the  analo<.ry  with  the  pnlliiif,'  of 
W(M.l,  the  pinekiiii,^  of  ilown,  and  the  like,  is  ino-t  ajipropriate.  At 
times  the  tremntou-,  jerky  nioveinent-  cxiiiiiit  p<enliarities  snirp'>tive  of 
tile  pre\ion>  oriiipjition  oi'  the  patient.  Ilowver  marked  the  inaiiifesta- 
tion-  inav  he  in  the  arms  and  the  hands,  there  is  ot'ten  no  partieiilar  niove- 
inent in  the  lower  extreiiiities,  or  at  most  a  certain  amount  of  tremor. 

M'itli  the  pro;.rrc---  ot'  the  di>ease.  and  in  scri<iii>  eaxs,  tlu'  tri'iiior 
and  Hoetitation  are  often  sihui  as-oeiated  with  rather  violent  mii-ciilar 
twitehiiijr.  which  is  al~o  more  iiiarki<l  in  the  trunk  and  the  iip|HT 
extreinitic-  than  in  the  lower  extreiiiitio.  This  may  displace  the  tine 
tremor  eiitirelv,  aiid  ajipears  (-i>ecially  in  the  forearms  and  the  hands, 
as  a  jerkinir  ]iroiiiiiieiiee  of  the  mux'les  and  tendons  and  the  relate<l 
fiiijrcrs — tendon-jcrkiiitr  (siihsiiltiis  tcndinum).  In  some  ea>es,  I'spe- 
eiallv  ill  jiatients  who  are  e\ee<'diiiL''ly  re-tlcss  and  liavt'  vivid  drcanis, 
more  or  less  niarkol  twitehiiijr  throujrhont  entire  iiiiiscle-jrronps  may 
heeonie  as>ociate<l  \>ith  tloctitation  and  suhsiiltiis,  esjH'<'ially  when  a 
piirjxisefnl  movement  is  attempted.  Tlii-  i-  then  hifrhly  sn<ri:estive  of 
true  intention-tremor.  At  tiiiic<  all  tlie~c  inaniti'stations  occur  over 
the  trunk,  the  four  extremitie-,  and  even  the  face,  naturally  always  with 
a  preiMindcrance  in  the  arms,  so  that  the  cliiiieal  pictures  ac<piire  close 
resemhlan.-e  to  a  severe  choreic  condition.  Such  ])heiioiiiena  were 
ohvioiislv  in  the  iiiiiid~  of  tlio-e  writers  who — in  my  opinion  incorrectly 
— sjxike  of  a  comhination  of   typhoid   fever  with  true  chorea  at    the 

'  The  (ii'cnrn'nrc  .if  true  I'horrii  minor  duriin:  c. .iiviiliscTiii'O.  ii-  lias  ln'i'ii  (.l-i'i-vcd 
ropoatcdly  tiy  Hartliiv.  aiij  Uillii't,  aii.l  ..tlirr-,  and  al-n  tiy  my-clf,  riaturallv  lias 
ncitliim;  tn  d"  witli   tlic  cuiulitiiin   under  coiisidi'i-atinn. 


^ 


2«M 


lYriidiii  I  i:\i:i; 


iB 


ft 

m 


lici^rllt  uf  tllr  t'llirilc  -IMLTI'.'  I  III'  rm-tlicf  -U|prrvclitinli  in  :lillllt-  cif 
tri-liiil-  nliil  ;i  t(l:niii--liki'  (iiiiili!  imi — i;iiiiiliii;^  i^t  llic  Inlli,  tniilc  cm- 
tr:iiliirf  dt'llic  ixtriinilii-  mihI  i>t'  tlii'  inii-cli-  nl'  lln'  li:iik  ami  llic  ii:i|i(' 
lit'    llic    iicik  —  i-    ((iliic    alai'liiiliL;-    ami.    Iiiiluiialrl\  ,    not     \ri\     riii|iirlil. 

Siii'li  attack-  ai'r   i ■(•  lVii|m  iil    aini  >'\'  -lii:iilii'   -iuiiil'n'am-i'  in    ii-rilaiiii' 

cliiidiTn.  In  ailiill-  iIka  air  llir  (•\|iir--i(iii  lilluriil'  a  imi-t  |irc)|liiiii(| 
t(i\ii'  action  ii|Hin  ilic  iriiiral  iicrNdii-  -\-i(in  nr  '>\  r-|iiiiaily  -(Atrc 
(•iiniiilicMlinii-,  aimin;r  wliirli  imninuiti-,  miliary  tnlpiTrnlii-l-,  and  -ciillc 
or  iininic  ('i<nilllii>n-  aic  ('-|ii'i'lallv  ti>  Ix  nnntioiicKJ.  In  rlillilri'ii  I 
liavc  ciiiMi'vvil  p'licral  I'limiiUinn-  witin.iil  -cmic'  r(iin|illralicin-,  ami 
not  larclv  tlic  ca-c-  icrniiiialcij  in  rccci\(r\.  In  adult-  tiny  arc,  in  any 
I'vciil,  cxticniclv  rare.  It'  liny  mciirrcd.  I  -lidiild  iii\aria!ily  -n-|icct 
conililicatiiin-,  or  rai-c  llic  i|nc-ti<)n  wlicthcr  tlic  dia;ini)-i>  nt  tyjiliiiid 
ti'Vcr   i-   -till    to   lie   adhered    tu. 

Hccansc  lit"  the  varialiilit\  ami  tlic  cuinliinatiim-  iit'  ccichral  and 
spinal  di-tiirlianec-,  c-|iccialK  nt  tlic  al>mi?-nial  imitnr  inanit'e-tatinii- 
aiid  tlic  ji-vcliic  -\in|itiini>  nt'  de|ir(  — idii  ur  cxiiteincnt,  tlic  cai'licr  |iliy- 
.•-icians  di-tiii^ni-licil  a  niiinlxr  nl  dillifcnl  v.irictic-  ot"  typli'iiil  t'cvcr, 
to  wliicli,  iiatiir.ilU  ,  only  su|Krlicial  -iLMiilieaiicc  can  lie  attadicd.  'I'lu' 
liest  known  ot'  tlic-c  \arieiic-  are  tlic  I'ollowiiii:  :  "  l'"cliri-  ncrvo-a 
>tu|iida."  tliat  varietv  in  wliicli  tiic  ]iaticnt>  lie  in  a  >o])oro-c  state — 
miirinnrintr.  trciniilon-,  w  itli  lloctitation  ;  and  "  I'cliri-  nervosa  versatilis," 
in  wliicli.  as  the  name  iiii|ilie-,  the  di-tiiri)ancc  of  coii-cioii-ncss  is 
associated  with  es]>ecial  restlc--nes-,  -nli-iiltiis  teiidiiium,  cliorcitiirm 
twitehiiiir,  active  deliviiim,  up  to  conditions  ot'  most  markc<i  ex<itcinent 
with  attempts  at    tliLdit   an<l   violence. 

It  has  liecn  pointed  out.  and  it  must  here  lie  eiiipha-i/cd  ajraiii,  that 
the  condition-  liitlKfto  dcscrihed  arc.  as  a  rule,  not  ilepcndent  u|hui 
aiiatoini.'allv  denion-tralilc  le-ion-.  I  have  i.otcd  the  condition  ol'  tlie 
l>raiii  at  niimeroii-  autop-ii  s  in  \ariou-  -tajfcs  of  typhoid  fever.  There 
is  |)resent  irciierallv  -nine  -e .lU-  inlilti-ition  of  thi'  cercliral  tis-ue, 
rarelv  marked  iivperemia  or  anemia.  Mrpceiaily  is  there  no  eontirm;.- 
tion  for  tile  statement  which  one  hear-  and  reads  now  and  then  that 
conditions  of  evciicuicnt  .ire  a— ociated  with  hyperi'iuM,  while  the 
"  fcliri-    nerv(     i    -iiipidii"  is   more   t'rci|iieiitly    dependent    ii|ion   anemia 

or  scrolls    intiltration  ot'  the  -nli-t.in f  the   liraiii.      Marked   cercliral 

eileina,  with  more  or  le—  marke<l  drop-\  ot'  the  vcnti-iclcs,  which  i-  so 
often  made  re-|»'ii-ilile  for  prol'ound  comatose  -late-.  I  have  rarely 
(■ncounlcrcd.  and  it  was  then  liy  no  mean-  alw.iy-  a— ocialeil  chiriii;; 
lift'  with    profound    stu|Mir. 

The    opinion    ot'  Licliermci-tcr,    that    the   fclirile   tcnipcr:i;ure    aloiio 


^YMI-lnMS  .{Ml  ((iMfl.lcATIoys. 


.Mi.> 


vvplaillrd  llir  -cvrrci.'-ciiinil  (li~tiirl):ilicf>  iiii  till'  |);il-t  uf  tlir  relit  I'M  I  lltrvniis 
-v-iciii  wliicli  liiivr  liillnrtu  liccii  ili-<ii"fi|,  li;i>  not  in-nviil  rnlircly 
-:iti-r:irlurv.  It  i~  Inic  lli:il  (jiiitr  L^'iiirally  llie  pnviou-lv  iiii|)Minil 
intilli^rciKc  i~  uli-irMil  t(iiiii|)n>\c  and  rcliini  in  tin'  .■.(■(|n(iic(' cit  n>|cl 
l)alli-,  anil  aU"i  iliat  <citaiii  cuniiilication-  atlrnilcil  with  rfdiictinn  in 
tiiniM  ralMi'r,  a-,  I'nr  in-tancf,  tiic  id'ulM-c  inti-linal  Ik  iiiuirliai:!-  truin 
the  l(o\\(l.  alnailv  niriiti(inc<l,  liavi'  tlic  sinic  cllici  ;  l)nl,  ni>'in  tin- other 
hand,  the  ehaiai  III-  and  {\\r  niaiiire-tations  ui'  eerehmd  di>tiMl)aiiee-, 
( -.|ieiiallv  tlie  vai'vinLT  dej^rree  of  >tnpi)r,  do  nut  eiirre>|H)nd  with  the 
heiirht  and  (lie  inten-ilv  ut'  the  te\  ef.  On  tiie  inntiiirv,  the  most  pi'o- 
tiimid  eereln-al  (h-tinlianees  may  .»'.iii'  with  ipiite  low  tempenitni-e  ; 
while  ea<es  of  ati  hrile  typhoid  te\er  afe  at  time>  attended  with  .-yin|>- 
toms  ot'  mo-t    pi'oiKinnei'd    iiei\iiu«   depl"i'--ion. 

Another  tiulor,  namely,  the  a<tion  <it'  the  toxins  n|M(ii  tlie  eeiitr.il 
iiervons  -v>teni,  is  lar  mofe  important  than  the  tem|M't^ittire.  This 
factor  alone,  iiowever,  diH^s  not  determine  the  eiianieter  and  the  severity 
of  the  distnrhanees  in  ipie-tion.  'riie-e  iieha\'e  and  nre  modifie<l  rather 
in  aeeordanee  with  the  remaining:,  espeeially  the  individual,  conditions; 
on  the  one  hand,  in  aceordaiue  with  aire,  sex,  eonstitntion,  heredity,  and 
anteeeclent  diseases;  and.  on  the  other  haml,  in  accordance  with  the 
P'lieral  condition  of  the  |)atient  or  that  of  in<lividnal  orjrans  as  iiitlii- 
enced   l)v  the   typhoid  disease  and  l>y  its  sta;r«'- 

With  retereiiee  to  iijre  and  sex,  it  can  readily  he  understood  that 
women,  children,  and  the  ai;ed  rea<'t  ditferently  than  rolmst,  ]irevionsly 
health\  men,  if  all  are  ex|>ose<l  to  the  action  ot"  similar  intlnences  n|H)ii 
the  centr-al  nervous  sv.-tem.  Anemic  and  plethoric  individnals  also  will 
exhiliit  ditVereiit  manifestations.  Amontr  conditions  j)resent  anteccHleiit 
to  the  atta<'k  oi"  tvphoid  t'ever  which  |iredi-.posc  to  profound  nervous 
disturbances  are  especially  nenrasthenia,  hysteria,  and  mental  or  physi- 
cal injuries  of  lout;  standini.'-,  an<l,  alwive  all,  emotional  distiirhances  and 
conditions  ot' depre-sion,  IhmIIIv  overexertion,  excesses  in  f<M)d  and  toxic 
substances,  -uch  as  inorphin,  hromids,  chloi-al,  eotfee,  tea,  and  esp^-eially 
alcoh,>l. 

Psychoses. — Althonirh  the  actual  mental  di-turUanees  ncrurring 
in  the  course  of  typhoid  t'ever  are  often  dirnily  related  to  the  febrile 
delirium,  and  arc  ot'ten  not  shar])ly  separable  from  it,  and  fre(|nently 
even  ai>pe;ir  to  arise  out  of  it,  neveilheless  the  character  and  pe<-uliarity 
of  their  onset   and  course  ren<ler  ne<'essirv  their  s|)eeial  considenitiou. 

At  times  as  early  as  the  second,  more  freiiucutly  in  the  third  wt>ek, 
peculiar  illusions  and  delusions  aiid  associated  abnormal  acts  stand  out 
prominently  in  some  |)atients  from  amonj;  the  general  symptoms  of  the 


ii' 


266 


rvi'iidin  hEvin. 


ft'l)rili'  -iii|Mir,  iiiiil  arc  woriliv  ul' >|M<iMl  imi-iilrniiiidi  liv  rrii-on  Dl'ilicir 
iiiili|Kii(lcn('c  aii<l  ji' iiiliariu .  In  pari  llit  y  ^oini  -iili-idc  witli  llic 
rciiiaiiiint:  tdirilc-  ~\in|iiciiii-  of  tlic  ailaik  nl  tv|iliuiil  liver,  in  |>ai1  lluv 
|Hr-i~t  iiiili'|iiii<liiill\   ami  "ili-tiiial<ly  llir  a  varialilr  Itii^'tli  nt'  time  alter 

(li  rervex'eliee,  ail<l  even  aller  ecin\  ale-eeliee  lia-  lieeil  e(iin|ileliil.  Ah 
lia^  alieailv  Keen  |iuinte<l  out  willi  re^^ard  lu  tlie  urdinarv  liirnis  nt' 
Celirile  (leliriiMii,  llie  iiieiital  edndilion-  iiinler  ll»>e  eiieiiin-tanee>  arc 
Verv  rarelv  -l.ile-  of  exeileinelll  uilli  aj:|rre"i\e  lelidi  lleie-,  lint  niorc 
l'r('<|Ueiitly  eiin~i>t  in  aet~  and  deln-inn-  that  exiiiliit  the  elianieter  nl' 
mental  de|ire~-iiin,  lit'  liar  nr  an\iel\,  with  or  \\ilhi>nt  liallniiiiatinn-. 
One  |iatient  may  "een|iy  him-elt'  with  f.niinndle->  .-ell-aeen-ation,  and 
lament-  a  lite  which,  iVdm  a  n  li;ri"n^  nr  nther  >tand|MiiMt,  lia>  lieeii 
\va>ted  ;  aniitiier  \\\.\\  iiear  \  uiei  >  nr  >ee  tij^nres  thai  de|ire— ,  |H'r-eeilte, 
or  threaten  him  ;  and  >lill  .iiidther  nia\  lii'  ri;^idly  in  Ixil,  nut  eatin;r  ">' 
di'inkiiiiT  I'r  leaetinLr  at  all,  iielie\  inij;  liim-elf  nmlidnle—  or  even  dead. 
Still  dthei'-  l»elie\e  tli.y  ha\e  ama—eil  j.Meal  lurlnne-.  which  they  Tear 
thev  ma\    l(i-i',  or  Hic\    >earcli  liir  and  lament  the  lu--  ut'  valnalile-. 

Althun^h,  a-  has  lieeii  mentioned,  the-e  ileln>iori-  ul'teii  di-a|i|>ear 
with  det'erN  t-cence,  neverthele—  they  iVeiiniiitly  |«  r-i-1  ihciral'ter  and 
hecutne  lixed  far  Inure  rreijneiillv  than  in  the  -ei|Menic  ot  mu-t  uther 
iiente  inlectioiis  di-ea-e-.  Ilii'  mcMtal  de|ire— ion  and  conl'n-iun,  or  only 
certain  niorliid  conception-,  ma\  then  |>er-i-t  in  the  |irc,-cnec  ol  an 
othcrwi-c  apparenllv  intact  -cnxiriNm  into  the  pcriud  ul'  eonvalc-i'cnce, 
or  even  extend  I'ar  licyond  it.  Smie  |>atient-.  alter  they  liavi'  hcen  out  ut' 
lull  fur  a  loiiy  time  and  a|p|ireciatc  the  natnre  of  the  di-ea-e  fiiiin  which 
thev  have  recovered  and  the  delirium  that  was  a— ociated  with  it,  are 
still  unalile  to  frei'  theniselve-  from  certain  imiici-atixc  idea-.  In  other 
n'-|(ccts  thev  make  an  impre— iun  *>{'  mental  i|nicludc  and  inielliffcnce, 
and  them-i  1\(-  admit  that  on  one  point  tlioutrht  and  s|Hecli  are  morhid, 
hut  thev  ai'e  con-tantly  iiic-i-tiliiy  impelled  llicrctu. 


Tliiis.  '  (iliscrvid  a  \i>imL'  iniirne\ man  lailur  w iiu  was  imalilc  to  IVce 
liiiMsell'  frorii  the  helief  ilia'  a  lieiievnleiit  wmiian  had  preseiitcil  liiiii  with  a 
puud  liral  of  iiiiiniy,  and  had  cuMccaled  it  fur  liiia  lieliind  a  cliiset  in  the 
ward.  I.iini:  after  the  jialieiit  had  L'utten  nut  nf  hed  this  tlimiLdit  could  only 
teni|Mirarilv  he  ilis|K'lleil.  liven  alter  he  had  iiiipruved  reuiarkalily  in 
phvsical  conilitiiin,  and  iiientallv  apiieared  entirely  clear,  he  was  only  liidf- 
ciinvinced  with  riLrard  tn  his  deliisiun.  lie  had  smiie  ilirtiileiice  in  s])eakinp 
of  it.  hut  every  now  and  then,  in  an  nnwiitclied  nmnieiit,  he  jrlanced  lunir- 
iiiirlv  toward  the  curner  necupicd  iiythc  proiiiisitiir  chest.  In  aimtlier  caw.  a 
wrvant-irirl.  eiirhteen  years  old.  durinir  the  fehrile  slaLa-  was  |M(ss«'ss<'d  liy 
the  ilelusion  that  she  jiad  heeii  visited  hy  her  uncle,  who  suddenly  liecame 
so  LTiatlv  disteniled  as  to  hurst.  While  (Jiiriuir  the  fehrile  staL'c  she  lamented 
hitterlv    the    fate    of   her    uncle,  she    lauLdied    liuriuL'    eonvaleseeiu'e    at    the 


r  ^   -.ii*. 


.s)  .l//'/'>.W.V   .l.V/^   tOMri.K  ATIO.SS. 


I'lu 


ihouKtil  "f  Ilia  |>«'ruliar  niflliixl  kI'  ilyiiiir,  liut  fVfii  utl«T  slii-  liiul  ln'cii  tW-e 
from  I'fVfr  iiinl  mit  of  Ix-ci  lor  wcckn  slie  could  not  rid  litTM'lt'  ol  llic  idea 
tliut  111'  iiiid  at  lca.»t  died.  AiioIIht  |iati«'iil,  a  r<loiit-Mfllir,  forty  vearM  old, 
Itfcariif  iiiC(T«<antly  fxcll<d  duriii;.'  lilt-  la>t  wt-fk  of  the  fever  ('(jik  eniiii;.'  Iii.s 
child,  wliich  he  tlioiij,'lit  had  lieeii  »loleii  from  him  liy  liei^dd(or>.  and  had 
Ihtii  cut  U|)  and  Imrned  u|i<>n  a  -and  heap.  The  hara.s-in;:  ihou^'hl  tollowed 
him  into  convalexence.  .\IIiiii|iIj^  were  made  without  avail  to  relieve  him 
of  this  delusion  liy  hrin^'inj,'  the  child,  which  wa.«  entirely  will,  lo  him.  A 
few  hours  after  the  depurture  of  the  child  the  delusion  would  return. 

It)  addition  lu  the  fonii  <d'  psyehii'  di-liirliain'cs  just  nientiiun'd, 
tliosc  uccurriiii;  in  in(ii\idn:iU  \slio  have  liy-teric  teiidencio  <li>er\c 
sptHMal  nniition.  1  have  oli»crvc<l,  piincipally  in  yonii^  women  and 
men,  condiiioii*  of  more  or  le—   maikeil  caiiile|i-\   (Hciirrin;;  a-,  early  as 

tile  seccind  week,  and  fidlll  tlli-  time  on  t<>  the  Ixriotl  of  defervescenei 

(inly  exceptiuiially  in  tlie  atilirile  |Kiio(l.  The  jiaiient-  lie  motiuiile*- 
and  cuinpletelv  nni'e>|i<in-ivc,  a|i|iarently  nncon-i'ioii-,  with  eye-  wide 
(i|M'n,  witlioiit  sleeping  day  or  niirlil,  taking:  "u  tixKl  or  chink,  and 
vnidin<r  tli<'  urine  ami  -tooU  in  lied.  .SikIi  ea-<~-  are  cdii-idered  liy  the 
ine.\|M'rience<i  as  of  es|H'eial  severity  ;  ami  the  nio-t  protuimd  ty|ilioid 
intoxication  with  deepc-t  coma,  or  even  rnenirii.'ilis,  or  extensive  meii- 
in;ieal  iiemorrha^'c,  i- as-nmni  to  exist.  If,  howevi  r,  -u<'h  patients  an' 
oli-eived  niofe  eiiticallv,  it  will  lie  foimd  that  they  react  to  very  -tronL,' 
anditorv  and   vi-iial   stiinnli,  c  \en   to  a  lond  call,  with  a  -ijrh,  increa-ed 

frcipiencv  of  witd<inf,'- nirdinati'd   voluntary   movement-  of  the  eye-, 

sudden  iieceleinitioii  of  pulse-l're(|uencv,  or  the  development  ot  an  emo- 
tional eivtheina.  One  can  s(h'  that  the  |iatient-,  thoiii^h  cun-ciou-,  have 
their  |Hiwcrs  of  i'X]iressinii  irrcatly  iniiil)ite<l,  and  lie  in  a  state  of  pla-tic 
Hexiliility  which  is  one  <if  the  most  certain  sijrns  of  the  existence  id'  the 
(".italeptic  -tate.  .\ft<T  this  clinical  picture  has  Im-cii  -een  a  few  time-  in 
its  mo>t  characteristic  form,  it  will  liecome  a|ipareiit  that  sliirhter  de^rrees 
(if  hysteric  stuinir,  with  more  or  less  marked  catalepsy  and  plastic 
tlcxiliility  of  the  mnscles,  arc  not  at  all  nire  in  prc<lis|>ose(l  individuals. 
Far  less  comiinm  than  the  tiirepiinj;  di-turliance-  arc,  in  my  experience, 
cases  (if  actual  hystci'ic  insanity,  in  those  patients  in  whom  I  have 
(iliserve<l  this  condition  it  did  not  occur  (hiring;  the  febrile  pi'riod,  but 
ill  the  earlier  ^Uiff-  ot'  coiivaleswiKte. 

Amdiifr  40()<)  ca.ses  of  typhoid  fever,  I  have  olis<:>rve(l  more  or  less  well- 
develoiied  psychoses  at  the  heii:ht  of  the  fever  iir  durin;.'  cimvaleseence  in 
42.  In  8,")  ca-ses  the  mental  dijitiirhaiice  iwrurred  durintr  the  febrile  stUL'e, 
in  2  duriui;  the  |M'riod  of  irregular  teni|ierature,  and  in  ")  duriiifr  conva- 
lescence. The.se  patients  were  exclusively  adidt.s,  and  w(inien  were  more  fre- 
([uently  affected  tlian  men.  I  noted  27  of  the  former  and  1")  of  the  latter. 
In  o2  of  the  eases  states  of  luelaneliulia  or  (|uiet  delirium  were  present,  with 


I. 


V  *  J." 


2«H 


TV  I'll' III)  1 1  vin. 


[p^-^- 


iir  witliiiiil  linlliiiiiialiiiii- ;  wliilr  in  llic  ri  iiiiiiinlir.  roiHlilinns  i>f  iiinrc  or  Irsg 
liiMikiil  CM  ilrrmiil  ami  i\rii  iii.'iiii:ii':il  .-lalcT-  \\t\v  nlixrvi-.l.  Willi  rcL'iini 
111  li\-lrrn|i.v(liic  ilirliiiliaino.  mikI  iT|HcJailv  llir  ralalfplu'  varirty,  wliicli 
1  liuvc  ul>-<rv(ci  lar  iimrc  Iri'iiiiriilly.  1  lia\i-,  iinrniliiiiatily.  iiii.-iali.-lii>.. 

(  )\vili;.'  tn  till'  til  111  lit'  III  V  aitis  il\  ,  llii'  mliilil  imi-  lliat  i  have  iiilliirto 
liirll  alili  111  ill -rlilii'  lliilil  lil\  |M  l-iiii.il  iiii-ilAaliiHI  Krliillj.'  allliii-l  lAilll- 
.-i\il\  111  llii'  |irri<iil  III  I  III'  ai'tiial  ili-ia-r  ami  llic  |ialiint  -  n-iilriirr  ill 
ihi  liii-|iil;il  ii|i  111  llir  tiim  ut'  riiiii|ilrli'  nciiM  IS  ami  ili-liii— al.  .\iii  li- 
i-l-  .111,  liiiui\  ir,  taiuiliar  w  illi  la-i- nl  iiniilal  ilininpiiuiit  lliat  ili\  rlii|) 
liiilrli  lali  r,  lull  wliii'li  iiniir  iiiii|iiiili!iill\  in  ciiii-riiiHllrf  111'  llir  altark 
111  l\  ]iliiiiil  ti\tr.  Tlir-i' la-r-  li  illi  i\v  iiii;  I  \  |ilii  liil  ti  VI  r  arii|uitr  iiiiiilii"ill 
a>  riiiii|iaiiil  wiili  tlin-f  liiljiiw  iiiLT  tlii'  utliir  iiili  rtiuii-  di-ia-r-,  ami  tlicy 
olltii  ixliiliil  iiiarkiil  -ixii-ilv  ami  nli-tiiiai  y  ami  |initl-arli'(!  liilllilimi. 
I    IliliT    lln-i'  rirrlllii-tami-  llir  rnmlitinll   i-  ll-liall\    mii    nt    ilr|ili'^-iii|l  up 

iiiilaiirliolia,  witli  -clt'-aiiu-atiun,  trar  ami  aii.\irt\,  -lii|iiir,  ami  dt'trii 
lialliiiinatiiiii- ;  ilimiL'li  mil  iiiiirli  Ir—  luiiiimiii  arr  i|iiiiii  r  ii.mliiiinis, 
wiili  |Miiiliar  iilia-,  r-i«i  i.iilv  ililii-iuii- nt'  jrramlinr  ;  ami  iiinri'  ranly, 
riiiiiimiiilv .  rniiiliiinii-  nt'  r\ritviiiciit  n|i  tu  till'  iiiiiiil  nf  mania  or  acute 
(liiiiciitia  (  K  latl't-Kliinix  '  )• 

Tiic  iiniiriiD-is  ui'  tv|(liiiiil  |i>yiliii-cs  a|)|M'ar-  in  genera!  tn  lie  favor- 
aliic.  (  "'  llic  ca-i's  imilir  iiiv  nli-i  rvatinii,  prcN  imi-ly  iiii'iilinncil,  wliicli 
<livi'ln]iril  iliirini:  till'"  t<l>rilc  imtIikI  ami  early  in  cnnvali-.cinc<',  only  '1 
|Hr^i-t(il  licviiiiil  .lie  piriiHl  nt"  cniival'x'cncc ;  tlio  nnc  tcrniinatcil  in 
niii\cr\-  at'irr  >i.\  niontli-,  tlic  other,  at'tiT  iii'ic  imintli>.  The  .-everer 
|„\,|],i.c-  al-ii,  wliicli  nece->itate  treatnieiit  in  hii-|iilai>  t'nr  the  insiiie, 
a|i|«ar  in  ireinnil  to  |iiir--ne  a  imi  iint'avoralile  eoi:i>e.  AecDnlinir  to 
K ratl't-KliiiiL'.  the  ]iriiirnii>i-.  i-  aliim-t  al\\ay>  t'avoralile  in  enmlitimis 
of  ijiiict  ileliriiim.  tiiiict  nr  even  -iii|iiiriin-i  inelaii<linlia  may  la>t  tnr 
month-,  lint  in  il"i  per  cent,  of  the  ea>es  it  terminates  in  recovery  ; 
rii'iiverv  from  eiinilitinii-  ot'  maniacal  e\eitement  ami  from  acute  demeiitiu 
occur-  in  troin  "iH  to  ti."j  [mt  cent.  n|'  ihe  caM'>. 

iSct'ore  leaviii).'-  thi-  -ii'tion  it  a|i|M'ar-  woilliy  of  niontion  that  in 
('.\e"eilini.''lv  rare  ea-e>  inarkeil  |)-ychie  ili-tiirliances  may  he  pre-eiit  at 
the  \erv  oii-et  nt'  the  .ittack  nt'  ty|ihniii  fever,  c\  ell  a-  early  as  the  Hr-t 
ilav.  nr,  at  least,  at  the  liei.riiininix  nr  the  midillc  nt'  ihe  tiist  week,  ami 
thev  may  then  exhiiiit  the  ehanicteri-tics  nf  an  iiiile|ienileiit  di-nnler. 
Sueli  cases  are  well  calculated  to  irive  ri-e  at  tir-t  tn  rror  in  diayno-is. 
I  have  nhserviMl  '1  ea.-es  in  which  patii  nt-  nt'  thi-  kind  were  at  once 
.sent  to  a  lios|)ital  fir  the  in-ane,  where  the  true  nature  of  the  disease 
first  lu'came   manifest    when,  aftir  the    lapse  of  eii:ht   and   twelve  days, 


1       .1 


t 


S)Mfl'iMS   A.\l>   f  01//7./'    I77"\\ 


2«« 


r, -|,.-,  tivrl\,  .iil;ii';;.Mi.nl  ..I'  lli.'  -|.l.  c  n,  .lianli.ii,  .iinl  .li-lim  I  r.-.nL.- 
in^l'li'  till  ir  .i|>|i":iliiliri  . 

■||„,  |.„  I  iliai  iIk'  |.ri\  iiiii-l\  iii-aiic,  if  i\|Hi-r.i  |u  iIh  |M.--iliilil  v  cf 
iiildioii,  aiv  alCi.  k.-.l  l.\  I\|.1m.i.1  Iim  t  :ilin..-l  :i-  Ir.  .|11.iiI  Is  ;i-lH;iltliy 
ill.|i\iclll;ll-,   -linlll.l     llk.\M-r    Lr    r.  .llM.l.  I- ,  1     ill     llli-    rolllli.l  inn.         I    ll.l.r 

Mlili  .iniiiii-laiir.-  ill.'  <■ mmiiiI  t.  riiiiiial  i.>ii  mI'  iIi.    -li-.a-i'  \ai>,a-  ill 

,,l|i,r   ,a-.-.    ill    a. nlau..'    uilli    iIh'    .■..ii-l'tiili..ti    .if   tin-    |iali.-m,    ili.' 

MV.rilv    n|'  til.,    iiit.rii a'        -II. -li    . -.11111. li.-ili.ni-    a-    may    I..'    pn-.nl. 

It    lia-    l.i.ii    Mal.-.l    llial    ilia    iiiliil"  r  ..f   -ii.li  ca-.-   afl.  r    iv.-..viTy   lia.l 

tak.ii  pla.-.-  tr..iii  Ih.'atta.'k  ..f  t.|ili..   I  Umv H.l.ralil.-  iiii|.n.\  .iM.nl, 

<,r  .\.ii.-..iii|.l.i..  iv<..v.r\  rr..iii  ili.>  p-y.  Ii.-i-,  ...■<  iiriv.l.  liiliTtiMiat.  iy, 
thi-  i-  ill.'  .■\rc|ili.iii  an. I  imt   ili'    inl.'. 

Nervous     Disturbances    with     Demonstrable     Organic 

lesions. Alll -Ii     lli.'   alV..ti"iis    ,,f    tli.'    n.iv..ii-    -\-I.iii    tliii-    tar 

.l.-.ril..'.|  liav.'  i...'ii  .la-..!  s.pai-al.ly  tr..iii  a  ihiiiiImt  ..f  ..ili.'r-  whi.li 
arc  kii.iwii  to  \<r  .i.|..  ii.lfiii  ii|m.ii  ma.r..-...i.i."illy  aii.l  iiii.r..-<'.i|,i.  ally 
«lciii..ii-tral(l.'  aiiat. villi.-  loi-.ii-,  it  will  r.a.liiy  Ih'  nii.l.r-I.M..l  tliat  .li~- 
tiii.ti.iii  i~  ii"t  filial,  lint  i-  .mly  an  i\|(n->i.ni  "f  tlic  iirf^ciit  >U\tf  .>t 
our   kiiiiwlci^r,..      Witli-.iit   .|..iil.t    tli.    -..-.•allfil    fim.ti.iiKil    (ii-tiirlianci's 

will    al'.i   in   tlu -.•    .>t'  time   lic.-.aiic   in.. re  aii.i    iii.irc  ac.i--il>li-   to 

anat.iini.'  iiivi'-tiiriti.in. 

Alterations  in  the  Meninges.— Anion..'  tlnsf,  iiiciiiiijriti>,  wlii.li 
is  nsiiallv  ii..t  contini'.l  t.)  tlie  lirain  al.iiif,  Iml  far  more  frfi|ii.iitly  is 
oorchrosiiiiial  in  di^trilmti.in,  slioiil.l  Ix'  incnti.iiii'd  tir>t  on  ai'.-oiint  of 
its  iniitortancc.  |)iiriii>r  cfrtaiii  ciiiiltiiiii-s  of  typlmiil  fever  ami  in  eer- 
tiiiii  places  iirof.iinul  nervous  di-tiirliances  which  can  Iw  ascrilie.1  only 
to  acute  iiitlainniatorv  |)r.KVsses  involving:  the  ineniliranes  of  the  hniiii 
and  tile  spinal  cord,  .icciir  in  the  .■.mrsc  ..f  the  disease  with  varyin^r 
frciiiieiicy,  at  times  in  lar;ri'  niimltcrs  of  c:ise>.  At  tlie  onset  an.l  .hirinj; 
the  coiiive  of  tliese  ca.-es.  the  >tnpor,  in  contrast  with  the  reniainiiii,'  symp- 
toms, is  slight,  if  present  at  all.  Under  such  circninstances  the  |>atieiits 
complain — a-  i>  iinnsnal  at  the  hci^dit  of  tlie  attack — of  ni.ist  severe,  per- 
sistent hea'lachc,  vertigo,  roaring'  in  the  ears,  and  ))li.)to])liol»ia.  At  the 
same  time  or  s<M)n  after  sicral  pain  and  l»ain  at  the  back  of  the  neck 
set  in,  with  painful  rijridity  ..f  the  vertchral  column,  esi)c<'ially  the  cer- 
vical portion,  and  chara.teristic  .)])istlioton.i-^.  Even  t.nicliiiiir  "i"  m.ivo- 
iiieiit  or  amcns-ion  of  the  dorsal  and  sacral  cervical  retrion  induces  loud 
expression-  of  pain.  In  addition,  twitching  and  pains  in  the  extremities 
are  present,  and  great  tenderness  of  the  skin  and  muscles  on  pressure. 
The  patients  aro  deprived  of  re.-t  and  sleep  hy  day  and   night,  and 

i..:_ 1    .— „ ,.,..t.,„*l,.        Tl.n    ^.,na,^r\'  nc  xvM\  !is  tlip  tcndiiloUR 

v.'»riiiin:iiu    auU    ^ivatt    v  •si-tcmt  tj- .         .  ...     ■ -.  ..■-'.^-    •*-■    ■•  ■ —  — 


'^^■'wmm 


III 


270 


TYi'iioih  ri:vi:n. 


%T 


r('tlc.\<'^  arc  j;("iiorilly  coii-idcniljlv  iiicrca.-'d,  aiul  t'lU'  clicitatioii  of  tlio 
lalttr  i-  c^iiccially  i)aiiil'iil  to  tlir  |iati('iit.  In  Mtinc  cax'*  there  is 
])ulviiria,  with  tlitlieiilty  in  niii  tinili<m.  I''a- iai  iierpcs,  wliieli  umler 
(iliier  eireiiMi>Iaiiee»  i-  rare  ill  the  eciiir-e  (it'  ty|>hc)iil  tever  (leeurs  \s  itii 
I'eniarkahle  rre<|Meiuv.  'I'hi^  -y ni|itciMi-eiini|ih'X  may  oeeur  in  Ixitli 
>e\ere  anil  niihl  ea-e-.  The  inten-ity  ot'  the  attaek,  it  -hiiMM  he 
e\|)re-«lv  iiiiintetl  (hii,  is  nut  ])rii]>iirticiiiate  to  liie  >eventv  of  the 
ineninjrilie  >\  in|itiMii-.  A  niiid  attaek  of  t,  jihoid  liver  may  l)e  atten(le<l 
witii  -evere  anil,  eunv  i  r-ily.  a  -evere  attaek  with  >!ieiit,  at  times 
tran-itory,    nn  iiintiitie    manifestation-. 

The  ihiralion  of  nienintiiti-  liurint:  t\  |ihoi(!  i-  exeeedinjrly  variahie. 
At  time-  it  i-  lium  li'iir  to  twelve  (la\-;  at  'tiier  time-  it  |ier^i>ts 
thi'onuiiont  tile  ureater  jmrtion  of  the  tihrile  perioil.  ( )eea-io'!;iily  it 
ev(  n  a|i|Mar-  to  jirolMii^r  t|i,.  letter  eon>ii'.eralily.  I  have  ohserveil  eases 
of  fi'om  tiine  to  three  ami  a  half  week>' dunition.  Hendiard  '  also 
pter-  t  1  a  ea-e  of  tweiitv  dav-'  duration.  I  have  never  ohserved 
renewed  a|i|>earanee  of  tiie  meniniiitie  -ymiitoms  diMMnj;:  a  rela](se  of 
tvjiiioid    liver. 

I  have  often  had  o|>]iortunity  for  ar, atomic  inve-tieatioii  of  ea.-cs  of 
tv|)hoiil  liver  whieh  had  -howed  -yMi|itoui-  of  eerehro-pinal  meiiin^dtis, 
Imth    tho-e    in    whieh    the    -ym|i!iim-    referaMc    to    the    <-entnd    nervous 

sv-tem  Were   sliirht  a mpared  with  tiie  -ymptoms  to  which  death  was 

diriM'tlv  attrilmtali'e,  as  well  as  tho-e  in  which  dcatli  unilouhtcdly 
ri-ii!tei|  direetlv  Iriim  eereliro-pinal  miiiintritio.  'i'lie  lir>t  ^iroup  is 
charaeteri/ed  hv  the  -lii:lil.  almo-t  nee'ative,  anatomic  evidence.  ( )ne 
mav  lind  at  nio-t  more  or  le-s  marked  hyperemia  of  the  -  if*  inemhranes 
of  the  hraiu  .mil  tin  -jiinal  eord,  witii  or  witiiout  turliidity.  \  marked 
advance  in  the  interp.etatinii  of  sueii  ca-i-  i-  fnrni-hed  liy  the  interest- 
iuL''  ol)-ervatii>n  hI'  I'l'.  >ehnlt/e-'  that,  althoue'i  imdcr  >\w\\  circum- 
>t,inee-  no  co,ir-e  anatiiniie  li-ion-^  .-iitjicar  to  lie  pre-cnt,  nevertheless 
small-ceil  inliltratioii  i-  deinon-irahle  in  the  nieiiilirane-  of  the  lirain 
.and    -pin:il  cord    in    the   eoiir-e   i.f  the  \e— el-,  and  al-o  nderu-copie   foci 

of  -imilar  cliaraeter  in  the  ti— i f  the   central  nerxcu-   -\ -lein.      In  .-> 

ea-e-  pre-eiitinir  inu-nall\  uc  ll-marked  eerehi-u-jiinal  -ympioiii-,  which 
were  ilMiiliile—  th"  direct  <'ail-e  of  death.  I  wa-  ahie  ,il  aiilo|i-y  to 
denioii-trate  the  iiimiliar  aiiatumie  piclin-e  of  |iuruleiit  eerehro-pinal 
meriinuiti-.  In  ■".  of  the-e  i-i-e-  e-|MMially  the  pia-arachiioid.  p;"'icn- 
larK  ipm  the  ciiiivexilN-  and  lalrr.il  a-pecl-  nf  the  lir:iiii,  w.-i-  iiiNolveil, 
and  in  h--  deirrei  that  nf  the  -pinai  crd  ;  while  in  the  'J  other  ca-es 
tile  liieiillir.ini-  I'f   the  iil'ain  .'lllil   the  -pilial    cold    were  eijlially    involved. 

'  j;n-l,;.    I.h„.     II'-.  ■    ,    |ss,,_\,,.   iOO.  '  I,.,-.  ,-,t. 


srMrroMs  ami  comi'I.hatkiss. 


271 


In  these  (sises  tlic  coiKlitioii  liud  (Icvclopcd  IkIwitii  tlu  sccoikI  am',  tlio 
liltli  V  k  ill  tlu'  course  of  attacks  of  tvplmid  fever  of  severe  onset, 
witli  ill  |>art  ^iii  uiiii.-.iially  inni,r  rcl)riie  sta<;e,  and  the  disease  iiad 
tcnniiialed  tiitallv  after  a  (hiratiuii  of  fnmi  >i.\  to  ten  days.  What 
relation  tiiese  e;ise-  he:ir  to  those  |irevioii-iy  nicntioiitil  in  which  there 
was  no  siii)|)iinitioii  mll^t  remain  uncertain  until  further  tiioroujrh 
liactcrioloj^ie  invc-tij^ations  lia\c  lieeii  made.  To  me  it  seems  ]irol)ahie 
that  ill  part  at  h'ast  tiiey  ditfer  from  one  anotiier  only  in  def,'ree.  In 
aiiv  event,  I  was  ahle  in  mv  i)Mrulent  eases  tu  e.\<lude  with  (•(•rtainty 
anv  undcrlvinj,'  coiiiiilicatioiis,  cither  jrcncral  >e[iticeiiiia  or  luirulent 
atVeetions   in   the   immediate  vicinity  of  the  >kull   [t-wr,  nose). 

My  cases,  wliicli  wort  oliserveii  at  tlie  hctrimiiiii;  of  the  decade  1><mO  S9, 
were  not  thori)UL,'liiv  exaiiiiiieil  liacterioioiricaiiy.  No  doubt  \arious  niiero- 
orjraiiisms.  ()<)ssibly  also  mixed  infection,  will,  in  the  course  of  time,  Iw 
found  to  he  the  cause  of  the  nienia^'itis.  In  this  coiineclion  attention  will 
have  to  he  <lireeted  es|>ecially  to  Siapliylo<o<-cus  and  Streptococcus  |)y(jgeiies, 
to  pnouniococci,  and  particularly  also  to  the  s|.ecitic  luicro-organisins  of 
epidemic  cerebrospinal  iiietiiiiL'itis.  1  would  direct  attention  particularly  to 
this  point,  because  in  Ilanibur;,'  on  two  occasions  I  observed  the  sirikinj; 
fact  that  severe  mcniiiL'itic  disturbances  in  the  course  of  typhoid  fever  were 
especiallv  well  marked  and  freijuent  at  a  tin  when  idiopathic  cerebrospinal 
nieuingitis  rai^eil  iu  the  <'ity.  Mesides  tli„se  cases  probably  due  to  the 
pyojienic  cocci  or  ii.euiuL'ococci.  it  is  tiow  i|uit('  well  established  that  a 
certain  number  of  cases  are  ilue  to  the  locali/alion  of  the  ty|)hoid  bacillus 
itself  in  the  ineniiiL,'cs.  Williin  the  past  few  years  a  number  of  such  ca.ses 
have  Ik-cu  reported,  and  have  lately  been  collected  by  Ilofniann.'  I^aviii": 
out  of  consiiieration  the  doubtful  cases,  at  le.isl  10  have  U-en  re|X)rted  in 
which  the  typhoid-bacillus  wils  dcfiiutely  oblained  from  the  menin;:eal 
exudate  iu  ])urc  culiure.s.  (  Hiliuaclier  •  luis  reported  "2  such  ea.-<es  in  which 
the  tvphoid-bacillus  was  most  carefully  identified,  and  the  histoloiric  ciianf.'es 
described.  .\  |)ositive  observation  hiw  also  been  made  hy  (^uincke.^  who 
saw  dealli  oci'ur  iu  a  workman  on  the  fourteenth  day  of  an  attack  of 
tvphoid  fever,  ainiil  symptoms  of  severe  (■crebrospinal  meninL'itis,  and  was 
able  to  demonstrate  the  bacillus  ot'  lOberth  in  the  incninLMlic  exudate  as  the 
sole  pvoL'cuic  ai;ent.  In  must  of  the  ca.ses  r<']M)rled  as  due  to  Hacillus 
typhosus,  the  condition  bas  been  one  of  a  purulent  le|)toinenini:itis.  In  the 
case  reported  bv  llofmanu.  howfver,  there  was  simply  an  iecrea.se  in  the 
amount  of  cerebrospinal  lluid  with  a  rouinl-ccll  iutiltralioii  about  the  ve.«sels 
of  the  pia  and  arachnoid.  flic  menini.'eal  s.  niotoms,  however,  were  most 
markeil.  with  (  Ionic  convulsions  durinir  the  six  hours  prccedins:  <leatli.  This 
c:L<e  brimrs  iorlh  the  interestin'.'  (piestion  as  to  how  often  the  less-marked 
meuiriireal  symptonw.  freipieiitly  -een  in  typlmiil,  are  due  to  the  presence  of 
the  typhoid-bacilli  in  the  brain,  cord,  or  cerebrospinal  tlniil.  An  iiiterestini: 
CISC  iu  this  connection  is  one  which  occurred  lately  at  the  dohn?  Hopkins 
Hospital,  in  which,  f illowiiiL'  ipiite  marked  menini.'i'al  symptoms,  incluclint.' 
stillness  of  the  iwvV.  an<l  delirium,  a  Inndiar  puiiclure  was  performe<l,  and 
from  the  cerebrospmal  lluid.  wliich  was  macroM'opically  (|uilc  clear  and  con- 

'  />.»/>. 7/    ,,ir,l^    11m,-/,..  .Inly  !•_'.  I'.iOo  •  I'l.iln.  M.;i    J..,ir..  .\iii,'ii-l  -JH,  ls;i7. 

'  SluliliMi,     ■  I'llior  t\  pli"-i'  ni(>iiin'.;iti-.'    /<i'r/i«    k/in.    U'nr/i..  18',)4,  l,'i. 


K  >.;•       .tun 


I 


:!U 


ii 

'■>. 

^- 

'15; 

eh' 

EL 

•J72  TYI'IIOID   IKVl.n. 

taimu  (ial\  ;i  very  ttw  |ius-ccll>.  llic  l\  |iliiii(l-liii(illiis  wiis  (>)>taiiit'ci  in  |iiiro 
ciillurf.  Al'lcr  M-\cral  ilavs  llic  niniiiiL'i'al  s\  iii|i|iimis  ciiliri'ly  ulian-il  up. 
'I'lial  ill  1 1  lu  tin  II  re  n.-drl  wVA  iimrc  l'ri-i|iicntly  It-  liail  lo  .-^iiiiial  |niiicturc, 
wiiicii  i>  al-'i  iml  rari'lv  iinlicattil  tor  ih(ia|iciilic  piir|>ii>cs.  t'lir  the  t'liiili);ri<' 
ix|ilaiialinu  nt'llii-  im  i  iii'_'iti<' .-\  mpii'iiis.  need  diily  U.'  iiiilicatcd  at  lliis  iilacc. 
It  is  ail  iiilfi-olinir  tad  that  iiicniii;.'ilic  syinplnni.-  (icca.-idiialiy  occur  w  it'.. 
{Treat  t'rcc|ucncv  in  ci  riain  cpidciiiics  ami  in  ctTtain  place.-,  ami  lliat  tlicy 
iiiav  tiicii  occur  in  L'roups  nt'  iii(li\  iiUial-  in  tlic  >aiiic  iioi-c  or  llic  ?anie 
t'aiiiiiv.  'I'liu.-i,  1  oliMTVtil  recently  in  tlie  .lal^oll^^pilal  .'i  !;ni>es  stricken 
in  c|uiek  .-ucccvion  «itli  l\plioiii  t'ever.  proliaiily  in  con.-iecpiencc  of  int'ectioii 
tiiroiiL'h  milk,  ami  in  a!l  ilie  ca.-cs  inenini;ilic  >yniploin?  preiloniiiialeil  I'roin 
tlie  tir>t  wci-k  lo  such  a  iJcree  that  in  the  liisl  <ase  the  .lia;.'-nosis  wa.s  as  a 
result  not  a  little  ohsi'iired. 

'I'lie  tact  that  eeieliin-pinal  -\tnptoiii-  .icciiriii  a  c(in-ii|eral)l(  niiriilier 
ofca-es  in  the  iati'  tiliri!<  peiiiid.  in  tlii'  stai:e  <d'  irre^nilar  telll|ierattire, 
and  the  tir-t  part  ot'  ion\  alesccncc ,  was  lonji"  a{;o  noted  hy  1  >iieliec'<, 
(iriessinjjjer,  I5iiiil,  lavden,  Kfl>,  and  iiivselt'.  1  tniniilitiilly,  these  eases 
iii'  nieninj^iti-  ari>iii;r  in  the  lat( f  |Hii(id  ui'  the  disease  are  tmioiiir  tlio 
tnore  severe,  and  liiev  attracted  alleiitinn  theretiire  relatixily  early. 
'I'iie  fact,  however,  that  marked  ineniiio-ilie  symptoms  may  ajipear  in 
tlie  earliest  iwriod  nt'  tvi>li(iid  liver,  and  may  so  thonititrlily  (ioiniiiati' 
tlie  elinieai  picture  that  the  ;ri'cate-t  dillieiilty  in  diaj;iiosi~  may  arise, 
was   ])r.ictic;illv  nnkiiown   lieli>re   1    called   attention   to   it.' 

I    have  exe<pti dlv   ohserved   ca-e-    ill    wliich    letnarkalily    severe 

heiidaelh  with  ritridilv  oftiie  tieek  and  hypire-tlie:-ia  e\iste<i  even  dtiriiig 
tlie  i)eriod  of  iiiciiliatioii  of  typhoid  tlvcr.  Move  frciiiieiitly  I  have 
(il)serve<l  til"  sMiiptiiin-  in  ipiestion  appear  on  the  tirst  or  second  tlay 
i\\'Ur  the  eommelieenieiit  of  the  iever,  i.t  times  iiatili-.illy  siljrjresting 
{retitiine  eercliro-pinal  meiiiimitis,  and  the  real  nature  of  the  eoiidition 
heiiifx  recoi:ni/e<l  oiilv  when  enlars.'cmciit  of  tlu'  sple<ii,  diarriiea,  and 
roseohe  appeaiMl  at  the  end  of  tlie  flr-t  or  the  iM'jrinninu-  of  the  -eeoiid 
week  of  the  disease.  I ■|idotil>te<lly.  if  .me  wishes  to  classify  siieli  ca.se.s, 
tliev  mijrlit  lie  desic-nati  <1  nieiiiiiuotyphoid. 

I  have  also  oliserved  ineiiiiii;itic  s\  tiiptoms  a]>p<'ar  on  all  the  stihse- 
<|iieiit  (lavs  of  the  fir-t  week  as  ^  '11  as  in  the  second  week.  At  times 
their  onset  was  marki'd  hv  a  chill  or  by  it  pi; i led  ehill>.  and  the  siir- 
prisiinr  development  of'  facial  lier|KS.  1  have  ol)-er\cd  these  ea.ses  of 
earlv  oeciirreiiee   far  more   t'reqnetitly  than  tlio-<   that   set    in  diiritifj;  the 

^  Sitziiti'ixlirrirlif  (!.  ('..inj.  f.  iini.  Mr,l..  l!.l.  v  .  S.  4i;!i :  iind  V  'VViiUl'  (;!op..rt 
fmm  tiiy  lii'imrtiiiciit  in  tlir  IliiiiitnirL'  Cincriil  ll..-|.itiil  .  />../'-■//  Arrh  f  him.  Mni  , 
I?(l.  xllil,  Kritz  ali'iic  ( /;V»./.-.<  r/uiii/ms  .</;,■  '/fiir-''  stimpf-  spninnr  i.hsrrr.  llaii  ir 
ti; <■!■••  typlii.i. I,'.  l';iri-.  T).'  lii  Ilavi'.  ISilli  ti:iil  nlVrri'il  t..  l.iU  CMtHii(i..ii  t.of.irc  I  di<l. 
ThU  latter  iiuliliciiliim  i-  l.iil  littl.-  kn..\vri:  my  ■■wii  iittuntion  wii,- dinctcxl  t"  it  i'V 
liiTiilitinl  i.iili   aflt^r  tln'  uijir-urmico  of  iiiy  .iwii   pnpor. 


' 


'-r^mW^^P^:: 


s? 


HYMI'I'iMS  A. Ml  COMri.KATInSS.  27:'. 

tliinl  week  or  lattr.  I'luy  :i|>|»:ii-  to  l>c  iiKirc  v;iri<il  with  rcL'iinl  to 
M'Vcrilx'    ami   course,    Ixit,   (ni    llic    whole.    iniUrr  than    the   latter. 

.">viii|)tiiiii'  oi'  iiieiiiiiLriti-  ihiiiii^  ilie  ((iiii^e  cit  .ill  attack  ul  t\  |ihiii<l 
lever  are  -eeii  aliii'i-i  e.\elii>i\ely  ill  vipiiiiix  iiidi vidiiais,  ill  males  less 
eniiiiiKiiilv  than  in  xMMiieii  anil  eliildreii.  I  have  nii-ervi'il  this  ediidi- 
lion  iiiilv  twice  in  |iatienls  over  thirty-live  years  old.  Aiimnix  .".S  ca>es 
III  vvi.'eh  I  have  mil  ■-,  'l'.\  were  in  wunieii,  H'  in  men,  and  ■")  in  children. 

It",  as  has  alieaih'  l)c<'n  ineiitiipiied,  in  eases  (i!'ty|ihiiid  lever  wit!  |>ri>- 
fiilil.d  -ttl])<)r.  >VMi|itiinis  oi' nieniii;_'ili-  dc\elii|>,  cs|iecial  atteiiliun  should 
lie  directed  to  the  |M)ssil)ility  ul'  the  syiiiptoni  heiii;.'-  dne  to  a  jiriinary 
purulent  proce--:.  'I'hiis  it  is  not  rare  liir  c\i~tiiiir  old  inllainniation  of 
the  middle  ear  to  nndcrpi  exacerhation  dnrine.  and  [icrhaps  in  (lonsc- 
(|iiencc  ol',  an  attack  of  tv])lioid  fever,  with  siil)>ci|neMt  e.\teii-ion  of  the 
proc     ;  to  the  incninircs.      I    lia\c   personally  oliscrvinl  this  in  a  ntmihcr 

.nstances,  and  in  '1  ca>cs  was  coinpclh  d  to  rcconimcnd  imiiiediale 
trejihininir  of  tlu'  mastoid  proce~s.  Menini_''itic  >ym|itoms  have  lieen 
ol)»crve<l  also  ill  the  seiniciice  of  recent  siippiinitivc  intlammation  of  tho 
niidillc  ear,  which  was  dependent  ii|ion  tyjihoid  fever  (Loiii-.  I'eacock  '). 

Cerehrospinal  meiiii-iriiis  is  (piite  mre  as  one  of  the  manifestations 
of  septicemia  eomplicatintr  typhoid  fever.  I  have  oliserved  '1  case>  in 
wliieli  sii  'h  a  condition  developed  diirini^  convalescence  in  con~c(|iienee 
of  pyemia,  followiiiix  extcnsi\c,  deep  hcd-sore-.  in  one  of  these  cases 
pnrnlent  -iniis-throinlx.  is  developed,  and  in  the  other  an  ah^eess  of  the 
hniin  a-  larm'  as  a  j)i^e<in's  etj-^,  ami  Iv.o  sii.aller  ])nrnleiit  fiei  in  the 
external    layer  of  the   liemis|ilicie,    were   present. 

I  have  ohservcd  tnlierculoiis  nieniniritis  ( xceptronally,  and  onlv 
diiriii<;  eoiivalescencc,  then  occiirrinir  eitliiT  as  the  "crehrospinal  firm 
alone  or  as  one  of  the  manifestations  of  a  c<implicaliii<x  ireneral  tnheren- 
losis.  .\ttention  has  heeii  callctl  to  this  Ity  other  wri^i.'  also,  as,  fir 
instance,   IVonsseaii.- 

MeniniTcal  hemorrhairc  not  of  inllainmalory  origin  occurs,  on  the 
wli  >le,  ipiite  rarely.  It  is  either  eircnmscrilcd  or  extends  over  a 
oon.-iderahle  extent,  mainly  upon  the  surface  of  the  brain.  The 
eireimiserihni  hemorrhairc-',  when  they  jrive  rise  to  .symptoms  at  all.  fill 
into  the  cat"ir(irv  of  fiKal  Ic-ions.  They  ma/  then  give  rise  to  liemi- 
plcfria,  es|x>eially  wirtical  monople^ria  with  jmiseular  twitchintrs  upon 
one  side  or  in  circumserilieil  areas  :  at  times  there  is  aphasia.  I^ess 
eommonly  the  latter  iK-enrs  alone.  ]-!\ten~ivc  nieniuirea!  hemorrhage 
has  hoen  ohservcd  hut  exceptionally.  I  have  personally  seen  2  crises 
in  mar'.i  lly  alcoholic  men  of  middle  age  who  proscnt<il  a  lieniorrhagio 

•  M-  Titrft  flnit  (iuz..    180ti.  '  Lite.  cit. 


m 


i  '  i 


Mill 


U 


274 


rvriioii)  ii:n:n. 


cdiiiM'  (if  lliv  (li-r;i-c  in  ^'.11. nil.       I>.alli  ...riirrc.l    in   <inr  at  tlic  end  of 

til.'  ~(c<>ii(l,  :in«l  tl llicr  in  tin'  inid.iic  "\'  tlif  tliinl,  wci'k.      In  IhiiIi  llio 

svtn])tcinw  M't  in  in  an  :i|>c.plr.litMini  tnanncr,  and  tlicy  pcrsi.-tod  for  two 
anil  three  da\>,  n-peetivelv,  nntii  ilealh. 

Alterations  in  the  Cerebral  Tissue  and  its  Vessels.— Tt 

lia<  1m.1i  iiiiiiliMn.Hl  in  tli.'  aiKitnniie  MT|i..i,  ilial  -viiipt.un-  depeiidriit 
ll|..,n  eoar-e  l,-ioii~  ct' tiie  eiiiLllil  ti-lleand  il-  Ve,--el- are  not  t're.|llent. 
Will  11  tiiev  are  jireM'tit.  llirv  oe<iir  jprineiiKilK  (liiriiiL'-  ill"  later  >taire-  <if 
tlie  di-ea-e,  in  the  la-I  |iarl  of  the  f.l.nle  period,  duiint:  eonvaleMenw", 
or  even  later,  ><>  that  they  niavwiih  (-p.eial  propriety  l.e  .le-iLTtiatcd 
,«'(|nel-.  We  have  oh-eiveil  hemorriiairi-,  e-uholiMn.  and  throiiilio-i~  of 
the  larire.  m.Hlerate-i/ed,  and  -niall  e.rehral  ve>-el^,  with  eireiini-erihed 
and  profuse  softeiiinir.  and  rarely  ah-eesse-,  a-  aiiatoniie  i'eatiires. 
Anions:  the  <'linieal  plieiioineiia  to  which  they  -ive  ri-e,  and  whleli 
often  dnrinir  life  are  dillienlt  of  eorivei  int(  rpivtation  with  rcjrartl  to  the 
aiiateini.'  Iia-is,  lieniipleLda,  with  faeial  and  hypoirlo-al  ].araly-i.-,  and 
riirht— ided  jial.-y,  oeea-iotially  with  apha-ia,  may  Im'  ]>oiiiled  out. 

I  have  perv>nallv  .iKs.rved  '.'  ca^s  of  tlii>  .liaraet.T.  In  the  one.  which 
tcnninate.l  lalallv  in  the  course  of  eiirhleeii  Imurs  the  ceiulilion  \\a>  depeu- 
.leiit  up..ii  icceiil'lieiiHirrhaL'e  into  the  left  I. ■Kliciilar  iHieleu>  and  its  vicinity  ; 

wlill,.  in  ilic  >. ml  c-asc.  %\ln<'h    lii^euiM-   icnniiiatc  d    talall.v  in  the  c<mrse  ot 

a  feu  .la\>.  ciiiholiMn  ofilie  left  Sylvian  arlcrv  \^a,-  present.  A  <'a.-e  proha- 
l,lv  su-ceplihle  ol' a  >iMiil.ir  c.\planal io.i  ha.~  h.-,  ii  ivpnried  hy  Clanis  '  '1  wo 
otlier  eases  nf  riL'ht-H.lc.l  henuple-ia  with  apiiasia  and  clioi-eilerin  luilchinp 
parti. •iilarK  in  the  aiin:-.  wliicli  wee  niider  in,\  el.s.-rvati..n.  t<  riiiiiiate(|  iii 
complete  re<-i.verv.  I  am  iiiHcrtaiii  whether  heinurrha-e  into  the  cerdiral 
lissu.'S  or  into  the  ineiiiiiL'es  was  the  imderlyiiiL:-  .(mditimi  in  tiie,-..  cases. 
Other  writers  also,  especiallv  « iricssiiiL'iT.-  .lackson.'  I'.eiiedikl.'  I'.erjrer.- 
N.iihiia-el."  and  Slrumpell.  '  re|HM-i  eases  of  cerehral  he.norrhat'e  'n  the 
C(ii:rse   of  tvphoid    le\cr. 


(  >>ler  ■  has  rcpnrle.l    the  <-a.-e  o|    a  ymni-  man  wlio 


during'  a  mihl  attack 


r.ftvphni.l  i;-\cr.  on  till'  ninth  day  ot'  iii:-  illne.-s  Middenly  developed  piural 
hihitei-al  clonic  <'..nvul>ion<.  wlii'ch.  tlidMLd.  pncral,  were  more  intense  on 
the  riLdil  >ide.  'flic  convulsion^  continued  al  inter\al>  up  to  his  dfuth,  ten 
hours  later.  At  anlop>\  liM-re  wa.- founo  tliromho>i>  of  the  as.  eiidiiifr  parietal 
ami  paricloicmp.  r;-,l  hmi.'ii.-^  ..f  the  mi.l.llc  cerehral  art.  ry.  In  a  >e.-..nd 
.•a-c.  thai  ..f  a  in.-ci  a-e.l  f.rlv->i\.  in  die  thir.l  week  of  a  m.ul.  ratelv  severe 
atta.'k  ..f  tvph.'id   fever,  iheri'  wa.~   a   -rinlual   ..nsel  o''  paralysi.-  ..f  the    l.'ft 

^j,|,,,      l),.Mth  urre.l  lour  .!a\-  later.  1  at  aun-psy  an  area  of  thromhotic 

>..fteninL'  in  the  internal  capsule  uas  f.Hin.l.  in  Iw..  other  ca>es  ..f  hemi- 
plegia with   >u.l.l.'n  ..n.-'l.  nuv  ..f  ili.-m  with   .■..iivul>i..ns,  tliere  wa.s  rcc(,very 

1  /„„,-.;.  />.N.-..   Wiir/l.uru'.   \s:  i. -.vr.^  .!■:/' ■>,  /    l<n,.l.'-h  .   IM    mi 

1    /,,„.    ,.,,  J    /.•./.),/-,    .1/../.   .^"^  .    iMiT 

•  Win,.  ,„.:l.   Pr,-,^'-.  WK  ^  l^.ri;,,    Liu..    If-.A,,  1s:o. 

•  Dr,,l.-..h    Arc/,,  f.  /,/,'.,   Ml      IST'.'       Tl,.-   |.;i)..r   .if   N.^tliiiH.'.  I    .■..ritairi^  »  r..rii- 
plol,.  r.n..!i-ii  ■■!   Ih.i  lit.i:Uur.-  up  t.i  l,«7-.'.'n  lln    ii.tvmu-  .,.,|ii.'f-  ..f  t\  |>li..i.l  f'.'vcr. 

T  l,J^rtmck.  '  J„hns  Jl,,j)kins  Ji„sp.  Jirji.,  vol.  viii. 


syMl'TnMS  AM)   coMI'l.IcATInSS.  27i 

from   the   t'rvcr  .villi  i>iilv  |iartial    rtKivtry   from   the   li(Mii|)li'L.'ia.      Wcldi 

iirlrric- 

a 


iiiciilioii^  4  olluT  fatal  ra.-H's  of  tliromhosis  of  the   iiiiili 


I'hral 


il.'i 


IL-  iiiadf  a  mo^t  carctiil  stmly  ol    li(Mii|ilcL:ia   iii   typhoul  ami  l.as 


ilK'clt'il   17  cases  fioiii  tlif  litcraliir 


T 


if  iIk-   ca.-rs   ilifd,  uiiil    in    liolli 


of  llicsf  ihcri'  wa.~  a  lliroiiil>osis  of  llir  iiii'lilli-  ivnliral  arliTV. 

I  liavc  iili-t  iv(<l  alp-c(-s  lit'  till'  Itraiii  Imt  iwioc  ii)  tlic  ciiiir-c  of 
tv]plii)iil  I'lViT.  Tlic  caM's  wrrc  tlmsc  uri'vinii-ly  nti'rnil  to  (|).  121  I, 
wliit-ii  were  il'pt'inlcnt  iijmiii  sc|)tii'(iiiia  aiiii  wire  attcinIiHl  with  imrilcnt 
m.iiiii^itis  ,,f  tilt'  cniivi'xity  ;  lli.'  rliiiical  syinj)ti)iiis  ami  nuir.-c  luiiig 
tliiisc  of  tlic   latter  cdiiililion. 

Ill  aiiilitioii  tu  aj»lia-ia  ilcpcmlcMt  iipnii  jii-uf niiul  ili-ca-c  of  the 
liraiii,  ili>tiirl)aiiccs  of  -pcccli  of  cortical  origin  in  the  coiir-c  uf  typlioid 
fcvcr  are  licscrviiiLT  ot'  sjH'cial  iiiciitioii,  since  i  hc\'  form  a  special  eninp 
iMiil  arc  characteri/c(l  hy  the  fact  that  ihcy  ucciir  alone  or  at  least  with 
onlv  circnniserihed  par:ilv^is,  innj  irmei-iilly  teriniiiate  in  recovery  with 
eoinparativ  e  r;ipiilit\.  If  they  arc  altcnilcil  at  all  with  inotnp  ili-tiir- 
haiiec-  in  the  irniik  or  the  extreiniiies,  thc-e  are  L'cncrally  ot'  the  char- 
acter of  tremor  or  ataxia.  On  aecoimt  ot'  the  rapiil,  favorahle  course, 
tli'se  casts  can  liardlv  he  attrihiitcij  to  oihei'  caii-es  ijian  to  -liirht 
anatomic  alteration  not  p"  rmancnily  injiiriiiL''  the  -peecii-i'cntcrs.  It  is 
peculiar,  I'liithcr.  that  these  ca«es  occur  alnio-t  -.i|.  ly  duriiii;  cijiivu- 
lesct'iice    and  cspecialh    in   ehildreii  and  youiiLT  |»r    iii-. 

I  l,a\e  |iers(inally  oliserved  llic  folliiuiiiL'  cases  of  this  character:  The 
first  iiccurreil  in  an  irrilahle,  s|Miiled  ^'irl  ten  years  old.  with  a  neurotic  predi.s- 
position.  who.  iluriiii:  convalesi'eiice  t'roi'i  a  severe  anil  prolracied  attack  of 
tvplioid  t'ever.  was  sinlileiilv  sei/.ed  on  the  t'onrth  ai'ehrile  day  with  almost 
coin|)lete  los.s  of  speech  after  sliirlit  disliirhances  had  heeii  noticed  on  the 
previous  dav.  The  condition  was  one  of  alaxi<'  apliasiii.  ( 'onseionsneiw 
and  the  retiiaiiiliiL'  functions  of  the  hodv  were  pres  rv'd  ;  1  would  note  espc- 
ciallv  that  no  paralvsis  of  the   e.\treiiiilies   ilev(do|  .At'ter  this  cuiidition 

hud  persisted  unehar.ired  for  two  weeks  the  disorder  of  speech  hcL'an  to 
improve,  and   after   the   lapse  of  live  weeks  complete   recovery  had   ensued. 

The  second  case  occurreil  in  a  merchant's  apprentice,  tifteen  years  old, 
whoso  mother  had  died  in  a  hospital  for  the  insane,  ami  who  prior  to  the 
oii.set  of  a  .severe  attack  of  tvplioid  fever  had  eliiriij-'ed  in  excessive  p!iy  "al 
activity  ;  he  likewise  \v:i^  .'suddenly  seizi'd  at  the  end  of  ilie  third  week  o'' 
the  disea.se.  in  the  sta;,'e  of  steep  curves,  in  the  daytime,  with  ataxic  aphasia 
which  was  accompanied  hy  considerahle  transitory  elevsition  ol'  teiii|>erature. 
Consciousness  remained  wholh  iiidisturlied  from  the  heL''nnintr  ot  the  dis- 
order. Iiiipro\ement  heiran  wiiliiii  a  week,  ami  in  the  course  of  three  ami 
a  half  wi'eks  almost  complete  recovers  had  taken  place,  except  for  sliirht 
ditficulty  in  formini;  words  and  syllahles.  wliii'h  ditticulty  persisted  for 
months.  While  still  in  hed.  and  alter  jre'tin;.'  up.  ataxic  distarhances  were 
(lemoiiMrahle   in    the   lowfr   extremities  :    sensation,    however,    helnjr    uiulis- 


'  Ahlnitfs  Suxti-iii  I;/   Mri/,.;iir.    \SW.   v 
'  Cltn.  Site.  Trans.,  vol.  xxvi. 


iii..  Lmuliin 


::iii 


111 


'-;  -  >..: 


Vi- 


tM.v^t^--!}?^^-:^^' 


1% 


27,;  rvriioin  ii:vi:n. 

,„rl,-.l  ...1  tl„.  ,..l..|l.r  ,..„.l,„MvtK.x,>  „nn,u.l.      'n..  ~.  Mt.xic  .listurl.uM.vH 
1,:„|  iil-n  .•omi.lrlflv  ,h-;ii.|..'Mn.l  iii  llir  .■.mrM      t   al.uut  I.  ii  vuvk^. 

l;..f,.n-n.vs  in  liir  lil.rat.uv  m  .l,i.  IH-uliar  vanrly  m    „,,  immu  -lat.^  I.M.k 
,.,  a  .•n„m;.n.liv.lv  .-.rlv  iHri.-l.      Afl.r  Kluxinan,,.      .a.,. M,h  .,,»■.    W  .  im'. 
.,,,,1   Tn  nsM.au  •  ha.lrdl.Ml  ultrM.i.m   tn  il.  (^MM.     an,l  Isu l.n  '  .n-aL'.^l  n,  a 
,„„n.  .hornn.l,  Mu.lv  „f  .!..■  m.I,,..-..      A.moh.   'Jh  .mm.  .■nll..,-.-,l    Kv  KmIm,, 
•':,   «..n.   in   .InMtvM,    an,l   tl.o   rrnKiinin-   ■■:    «-■.■.■   nl.-.    m    vnni.u'    l>.rs..nv 

Ev.vnt    fur  tia.    pivsr.av  uf  ataxia    n,  •.'.as.-.-.  Isnin,   ^"^   -l    r.t.r   f  anv 
„,lu.ra.s,..iaI-.,l,uTV,.n>aistnrl.anr...   in   l,i.  <.,>.■..      I  ..-all,  ...Turn-l    n,    l.u, 

1.  ul.il.-  .•nnipirf    rrcovcry  .■n.-,,,.!    ni   lia-   nn,ain,u-r   n,    li I.r.v   K.  mn 

wi'cks,  rarely  lalrr. 

OtlHT  fonn-   ..f.rni.ral  n.nnn|,l.-ia    inv.lvin-  tla'  arrn>,  tl,r  1.L-,  or 

.,„lv  ,.,.rtain  -. ,„  of  nni-rl,>,  havr    lik-wi--   Kr.n    ,v,Mnl..l  .A.v,.l,on- 

allv  in  tlu'  ill.ratnnv      Tluv  liav,  liuw.vcr.  not   I.c.m.  .•arcfnlly  n.v.-ti- 

p,i..l.  an.l   Ilw  .un.r.tioM,  .-iu--ially  in  tla^   ol.Vr  ra-vs  rannot  !«•  .1,-tm- 

irni-lK<l  fri.ni  .vrtain  varictii- ol'  ]H'riiili.ral  iiinnli-. 

Il,.tnnn-liai:c  an.l   innann..at..ry  s„fl.Miin,t,'  ..f  tl:f   m.'.lnlla  ..M..n-ata 

(l.-crsc   >i>.iiai    ni.nlii.n. 

TiK..'as...ftins  kin.l  r.i.orU.,1  l.v  Knnnm.ll'  is  intercstinL',  as  il  pursne.l 
tl„  '  ,nrs.  ,.f  an  a.a.,..  a.vn.Un.  ,,araU>is.  ..s  .li.l  ais..  tl...  -as.,  nt  s-.U.nn.g 
of  tlK.  l.nll,  «i.h  .apillarv  luna-rrhap-.  «ln.i,  uas  utwier  n.y  -jl.s.rvat urn 
,s..o  Ana.oM,v.  ,..  I'-'n.  'riu.  la.l.r  ...•••urr.-.l  ,n  a  u,an  tlnr.y  y.ars  ,.1.  . 
viw,  «as  l.rnn.'ht  t..  .he  hospital  fn.n,  .h.  harhnr  prnt.,nn,lly  .1,  n,  a  .  o.n. - 
,0M.  s,au..  «ith,M,t  anv  history.  Th.-r-  ..r.  n.-h  ..v.-r.  n,n.U.ra,..  nuu-"r- 
is,n,  ,al,.al.l-  ..,.lnr...nK.nt  .,f  the  spl....,.,  r,,'..i..y  .>t  th.  n.rk,  an.l  sutl,  .-^ 
of  ,1,1  Jn.ir.  v..r,..hral  .-..Unnn.  hy,H.r.s,lu.sia  .>f  .h.  ^hol.  hn-ly  .x.^ns  e 
lal.ial  n..r,...s.  l.nt  n..  rns....la..  iK'ath  ...•.•urr...!  ,.n  tl,.;  s...,n,l  'lay  ..t  r.s,- 
hi  ,  '  in  lu.  h..s|,ital.  Tho  ant,.,.sy  ..is.-lose.l  .:..•  hsu.ns  ..t  an  -t.a.k  of 
tv  1  oi.  fev.r  a.  he  -n.l  of  .h..  third  week,  an.l,  in  "..hi'--";  the  hnll.a 
i:J|„ns  ,nen.ion..,l.  n,ark..,l  hy.K.r.n.ia  of  the  ,,ia-ara,hn„.,„l  the  bran,  and 
the  soinal  o.nl,  «illi  sliirht  tnrl.i.li.y  of  the  .•.•■■el.r..s|ana    Ihii.l. 

The   ease.    re|..,r,e.l    l.v    Kis..nlohr »   n.ay    ais..   I.es.    he  e.te.l    here.  e 

deseril.e,l  :!  .-asej  of  ....nsi.i.n.,ns  inv..lven,en,  ..f  .he  '"''  ^  ;-|-  ■"  ^ 
course  .,f  tvphoi.l  fever,  «l,i,h  vvre  .  hara.-.en/e.l  e.s,.ee>allv  l.y  .1,  s.,  thr  a 
Z^^vsi.  in  the  .iis.rihu.i..n  ..f  .he  fa.ial  nerve,  an.l  n,  ,.ar,  .,  .he  n,., ...r 
S  .n,i,.n  of  .he  ,ri...,ninal  n.-rve  Mv..akn...ss  or  s,.a.^n,  n,  .he  nm.sse.er 
;;;.;:;U.s  ,.  ah  :;  ,.a,i..n,s  ..xhil,i.e.l  evi,l..n.-es  ,.•  pn.  .un.l  ■;;--<>-;»";'  ;^;- 
at.aek.M  ^vith  ih-  n.rvons  svni,.t..ins  .Innn-  .he  tel.rih'  Ma-e.  In  -  <.i  <« 
r  eos'rv  enM,...l  «i.h  ....,n,iara.iv..  ra,,i,li.y,  .hie  '1-  ,-■"--•;;.  - 
thir.l  an.l  .!..■  a.,t..,.>v  ,li..'l.«..l  as  .he  eans..  t..r  .!..■  .n.ul.le  n  va.M.,n  ..f  tht 
:  nl  lhl..n.a,a  l.v  ..r.anis.n.  r..sen,l.lin.  S,aphyl..eo....„s  '''---,. y 
,K-.niiar  l.a.llli.      As"  in  n,y  .  ase  ..f  invasion   ...   .he  spn.al  .-nl  l.y  .yph....l- 

I   I'rr,,..^  ,„r./.    \:'rr:„sr,;> ,,   lS.-,4.   N^'    l'.^.  -     .  -     ,     ,       ,  Rr  4 

-•  <:.,„pf    ,:■„./.   .!■■  In  S..:  .Ir  li,..!..    l^.'.O  '^    r^.r.,.    h.ndrri,..    ISf,.. 

e  nr,„.r,.   aU/.  kl.,.    M.l..   IM^   vvviv       Tl.i- ..in-    al-.  A.  ^■..S■^   roU-r.ur. 

to  ,h..  ii,.-,^.ur..  ,.,,;„   yr,.-    ,M.ii.ll.r>2 

»  I)r„tsrh.  ,nrd.    W"rh..   IS'..:!,  .N...  •;. 


'.'.'•  ."^ "'   V  "/^a't/  \ri5'>^*;-r-, 


SYMrinM.S   .\.\l>   (  ijMI-I.IC]  l,ii.\S 

Imcilli,  s<i  also  in    KiM'iiliilir'>  filial  cum'.  M-iircfly  aii\  aitiial  iK^inictixn  of 
lissiii'   in   llu'  tiiiMJiilla  (ililoiiL'ata   was  (IciiKiiislraKlc. 

A  ca-c  iiiiilir  my  (iliMTvalidii  in  llic  vi'ar  \f<>^\.  U>  wliii'li  my  altcntiou 
was  aj  MM  lallicl  only  after  the  a|i|H'aran<T  of  KiNiilolir's  rciMirt,  may  Ito 
iii'luilcl  in  tliis  -roiip.  It  ociairicii  in  a  xTvant  ;.'iri,  ninfltin  ytiir>  AA. 
Milfiiint:  from  an  attack  of  lyplioiil  f(  v.r  of  m(»lirali-  Mverily.  \l  lIu'  t'lid 
of  ihr  ihinl  wc.k  (li.-tiirlianccs  of  >|>».'«-<li  -imilur  to  llio«'  ilcr^crilMMl  liy 
Ki.-cnlolir  siiddinly  apiHari'd.  Tlio  Feiisorium  was  clrar,  tliire  was  n<i  ..iIut 
paralysis,  ami  tlu'  iiuiscics  of  niiLslii'atiin  wcrf.  accordin;.'  to  my  notes,  intact. 
("om|>let«'  recoverv  t'radnally  ensued  in  the  course  of  four  and  a  half  week-s. 

Certain    eei-einal    iitrve-    a|i|Mar   to  lie   involved    liiii    rarely    in    tlic 

course  of  tvpiioid    fever.      Facial   or   iiypoudo-sil    pare-i-    i-    iiieiiti 1 

oxce|)tioiiallv.  I'os-il)iy  tlie  l(\v  ivp.irtcd  <'a>e-  of  par:ily.-is  of  aceoin- 
niiHlation  (liiiiii;.' eoiivalescenee  ((iiililcr.'  Kutel")  Kelouir  in  this  jrfoiip.' 
The  oceiirn'tiee  of  paralysis  of  the  vcxal  eord>  i-,  in  |>urt  at  lea>t,  lo  he 
incliidiMl  here;  while  an.ither  ]»<rUi>u  oltlie  ca>c.-  are  attrihntaldc 
(lirectlv   tu   liHvil  disease  of  the    larynx,  '-itch   a-   inilaininatory   swelliiifr 

(if  the    niiK s    ineinlirane   ainl    the    sulmuicon.-    tis-iies,    and    ulceration 

(see  ji.  2V.^  and  the  siicceedintr  |iai:e-).  The  condition  present  in  the 
first  class  is  inidoitlitc<llv  one  of  innervatioiial  distiirliaiK'c  in  the  dis- 
triliiition  of  the  rccMrrciil  laryntrcal  nerve.  bilateral  or  unilateral 
|>aralv-is  of  all  the  tniiside-  su|i|ilicd  hy  this  ncrvi  has  lint  rarely 
been  ohservod  ;  more  freipiciitly,  jiaraly-is  of  certain  frmiips  of  niiiseles, 
especiallv  of  the  alidnctors  of  the  vo<al  cords,  and  soinewhat  less  coni- 
itKitdy  that  of  tiie  adductors. 

The  earliest  reported  cas(-  is  prohalily  the  well-known  one  of  Traul*.'  iu 
wli'di  iiaralvsis  of  the  vocal  cords,  tou'ether  with  other  ^  vere  nervous 
manifestations.  devel<i|K'd  durini.'  the  first  week  of  the  disea.-e.  Tiirk  and 
Nothnni;el  ( wh.c)  i.'ives  the  earlier  literatiiriM  liiive  reported  similar  eases. 
An  f.xtensive  stuily  has  recently  lieeii  pn  lished  liy  ]{oulay  and  II.  Mendel. •■ 
Lul  '.iiskv*  also  deserves  credit  for  his  investiiratioii  of  this  siilije<'t.  Other 
oa.ses,'  especially  of  paralvsis  of  the  crico-arytenoideus  (Histiciis,  have  l>een 
repi)rte<l  liy  Liinintr."  Kehn.'  .Touras.se.'"  an<l  Pel." 

S'nsorv  distiirliaticcs  in  the  distrilnition  "f  the  cratiial  iiervos  apjM'ar 
to  lie  own   more   infreinient   than    motor  distiirliaiiics.      'I'rifacial   neii- 

'  An-/i    •!■  II    ■!■■  .v../.  lsi;0.  -■  IIV,«    iiiril.  /,•//,.  I8i;.-,. 

'  .'>i'C  fiirthiT  ;it  .1  l.it    r  |.;e,'r  the  (lis-i'iitiirLT  npiniori   i.f  Kur-t.-r  iiikI  Kni<'~  '\i.  2h:i\. 

«  (Usiimmelti-  Hr!tr,i;i,.   IM.  ii.  '■  Ar.-/,.  iihi.  ilr  Miil..   Dee..   '*;i4. 

«  nnitirh.   »i.;l.    ll'...-/,..   IS'.!.',,   T.'o.  '.'«. 

'  Th.'  iiinii,)i.'rii|)li  of  1'rzccll.nr.lii  |  \'..|l<iiiami  -  Snniwfii-iii  klhi.  Vortr..  May. 
18'.<7,  No.  ISLM.  wliirli  a|ipciir.>(l  wliile  !lii>  v.ilumi  wii-  in  pr<'>v  iittCTiipts  to  show  that 
piiraly.-i*  "f  tli.'v.M;il  ,..nl-  in  ih.'  .■mir-i'  ..f  lyplioiil  f.'viT  i-  ;i  ijiiit''  fr.-(|ucnt  .■c-iir- 
ri-ncc.  KurtliPr  iili.-orviili..n-i  will  lie  re.|iiin-il  te  il>'t.Tiiiinf'  t.>  wlmt  extent  tliis  striking 
statrmiTil.  wliiili  i-  ciintniry  tn  tii.'  e|iini..n^  liitlnTt..  lirKi.  i-  oorroet. 

»  hntinfuhrrks  Arc/lir.    liii.    XXX.  '■'   Hiiifsr/i.    Arr>i.    t\   l.liii.    M'-'l  .    li'l.    Nvili. 

'"  Dnilsi-h.  inetl.   »'i:-/i..  1H79,  Nci?.  Hand  L'l.  "  Virc-liow-IIiis.li,   1870. 


-^^-     "'^/M     y^:     ^^^: 


Wn 


^M 


•J7.S  rvi'iinii)  I  III  i:. 

r.i].i\:i.  |M  r-i-liiiL'    int"  c"ii\  :iI"-i"Ihc,  i-  n  tciTiil  to  liv  \;iri(pu-  nl)-.,r\rr«, 

,r  nilici-   li\    Mnimiiill.       I    \\A\<'    I"  (■-•iiially  (ili-crvnl   m-c   nt 

till-  cliMiiKii  r. 

Affections  of   the    Spinal    Cord.— Tin-.'  mI-m   nn    (I..mI>iI<>s 

(|iiilr  nil-.',  iniirli  i;in  r  tli;iii  wa-  IpcI'ha  cil  at  a  liim-  wlnii  p.  ri|.liiral 
li.iirili-  anil  it-  iliiiiral  iiiaiiiri-lalioii-  win;  lilll.'  kii.>uii  aii<l  para|ilci:ia, 
iiarliciilaiK   '•!'  iIk'  Iiumt  iA!rrniitli- ,  wa-.  willnnil   I'iiiiImI'  ■■■■ii-iili  r:;ti(iii, 

.la-c.l  ai vj:  llir  -|iiiial  .li-.a-.  -.      \'<>v  llii-  iva-Mi  llic  larlicr  lil.iatmv  ' 

.•aniiiil    Im'    aircplcil  uillmiii    .|iialilicali'iii.      (  a-c-  <>i'  mvilili-    diliiiilily 

(Miiiliriuiil  l.\    anal ir   .■li-.Txalii'ii-  have.  Iiowi  \(f.  Iici'ii  nli-irvcd    in    a 

niinilMr 'it'  in-lami -.      Sik  li  a  <:i-r  wa-  irciiilly  uli-(r\<i|  in  my  .  liiiic 

I  iiia\  at  llii-  [M.iiil  rrt'iT  alwi  In  I  lu'  la.-c  .lixTilidl  I'V  iiif  in  !.*<>»)  m'c 
nl>"  n.  1-1  .  ill  "li'il'  a  -IriinL'  man.  lliiil\ -mi'  vi^ais  "M.  iliiil  in  llif  lii->l 
li;i.l!'  nf  till'  -iciiHil  \Mck  'if  an  allark  ol'  l>|ilii.i.l  ti\.r.  uilli  iii"-t  iiiai-k.-.j 
!iyni|.niiiis  nf  arulr  a.-ciiMliiiL.'  '  Laiiilrv's  >|.i.ial  |.ai-aly.M>  -  nr,  il'  lliat  liTin 
]\i-  |,n  f.rrnl.  myrlilii'  !irini.->iiii'i  .  Mi(rnMu|.ii'  ami  ranliil  liacl.  lanln^ric 
I'Xamiiialiiiii  nf  lln-  -|.inal  innl  ai>c|o>i.|  li.^Miml  ilniilil  iiiva-imi  Ky  ly|ili(ii.l- 
liMiilli.  wliirli  riiiij.l  Im'  .l.iiiMiislral.Ml  Imlli  in  iraii^MTM'  Mclinii.-.  ami  in 
<",;lliin'S. 

A  ca.v  :.liiiii>l  iiliiilii-il  willi  my  nwn  liail  1h-,ii  iIim  i-ili.il  liy  l.ciiiKl-  in 
ixiil.  II  i^  iialicnl  «a>  Mi/.cil.  in  llif  lliiril  wnk  i.fa  mil.!  allark  ut' typlioi.! 
fV'Vi'i-.  iifhi-  -lie-  liaij  ai'liiaiiy  rnlcTfil  U|"in  (■iiii\  ak^cinri'.  willi  aciilc  >|iinal 
|iaraly^i>.  a.-ri mliiiL'  iVnm  llic  !■•«•  •  iMrmiilii'S.  wliidi  itTiniTalcil  fatally  in 
tlic  ciini-M'  nt>.  \in  ila\.-.  uilli  >Mii|ili)inti  nf  aspli\  xia.  ami  iii  wliirli  coii- 
>iciiin>m»   «a>    pii -cr-, cil   ilirini:;liiinl. 

A  Minii-wliat  similar  cas.-.  |irii\iiiL'  'alal  at  tlic  "IhI  nf  fi-lil'cn  limii-s,  has 
li.'cn  ri'|iiii-lr.l  i>v  S.-liiir,  'I'll.-  rxaninialinii  nf  llir  inril  in  llii>  raM'  -liiiwcd 
an  acailc  lii'innrriiaL'ii'  iransvcPM'  niyclili-  at  llif  level  nt'  llie  In'irili  ami  tilth 
cervii-al  .-eL'nient>.      (  nlliin>  in  this  ea.-c  were  iieL'alive. 

I  kimu  lit'  III!  I'lhei-  Hiiiilar  ea.-e.  They  thus  appear  tn  he  (piile  rare. 
^Vh(■ll1l■r  in  future  iase>  liaiilli  will  he  ilemuiistrahli'.  as  they  were  in  inv 
ease,  in  the  tissue  of  the  etiitral  iiervii;;s  .-ysteiii,  eanmit  he  stated  in 
ailvaiiee.    ami    their    presem-i     is    pii>silily    nnly    «t'   snhnnlinale  siirnilieaiiee. 

It  is  readih-  r -ivalile  tliat  ;"\ie  ell'eets   nf  .■>pirial  severity  iiiav  -ive  risi> 

to  similar  svmptnms.  It  is  nntewnrlhy.  t'urlher.  that  i|uite  similar  severe 
romlitidiis  n|'  anite  asc  cniiiiiL'  paralvsi-  ha\  e  heen  ilesia-ih-  '  in  the  rnurse 
<if  nther  infeetinu-  ilisea^e-  al-n:  fur  iiistam-e.  in  ease>  nf  \arinla  hy  <  iuhler. 
IJernhanlt.  ami  .tliei^,  h\  l.amlr)  in  eases  nt'  iliphtlieria  ami  ehnlera.  ami 
Ipv  the  latter  iin      i.i-yileu  in  ra<t>  n|'  pmunmnia. 

Still  iilher  eliiiieal  pietiire-  iiiKJiiiiliteilly  of  -iiiiial  oriu'in  liave  heeti 
i.li-er\eil.  'riiii-  We-tiilial,'  npnii  the  ha-i-  nf  a  ea-e  teniiitiatiii^:  ill 
reeii\cr\  .  has  called  attention  tn  a  peiailiaf  variety  nf  marked  ataxia 
I'ullnwiiiir  tvplmid  lever,  as.-.xiated  with  tfeiimr  in  tin  Inuer  extremities, 
xvillmut    aetnal    itnpainnent    n|'   •^v<'-~    -Ifem^th    nr    of    -eti-ihility.       1  lit" 

I  >,■■•  til..  inMii,.^.r.-,i.li  -r   N..tliiiie_'.  1  ■  '.'I-    »„.'.  ./•   r<ir,..   1.-<C,1,   No.   1(1. 

'    ll,.,i^rl,      Ar.-I,      I      I.I.,'      Mr.l       l'"KI      lid      Iwii, 
•  Arf/i.    I.    fsu.-h.    u.    .\.-rr  .    IM      II!   ,    llifl  -J. 


■u^Srii 


.^|•.^//'■/•'^W^■  .I.V/<  ciMri.K   \  IIDSS. 


ry 


.•.m.liliun   was   ass.-i:it.Hl    uitli   .li-..i-.l.i>  ,,f  >ik...,1i  nf  tl,..  l)iill.Mr  tyiK^ 

n-.ml.liii;:  tl.n-c   :ill.iJi.i-    inullipl.'  >.I.T..>i-.      A  -iinilar  ..lilim.  lias 

a|,|,ani,llv    1..-. 1,-rrvr.l    \>y    Kirl.lioiM    ainl    Slnim|Kll.' 

Mulii|.lr  ii.-ular  -rl,r..-i-  lia-  al-..  l-.n.  .,1,-.  rvr.l  .lii.i.ally,  an.l   in   a 

nntnlMi-  of  i„-tan.i-   ai.al iralK.  in  ra-.-   -t    l^['U'<\A  Hv.r.      In   .•-.„,- 

|.aii-nii  witii  it-  ...■riimiic'.'  in  "tii.r  a.iit.-   iiiLMiidi-  .liM:i.-( •^,  liii-  <"i>- 
•  litioii   app.     1-    t"   !»■   IK'I    <\liviiiily    raiv    in    tvplioid. 

I'ierrf  Mari.-  ..bscrvc.!.  ainoni'  'j:.  .asrs  of  iiiMih.r  M-lerosi:'  .l<.j).n.loMt 
UlM...  inf.cliaiis  ilis.as.s,  11  in  w  liidi  tliif  n.tidili.Mi  «a.-  a  m^milI  «i  lyj.h.M. 
tVv.T  The  niilitarv-sanitarv  r.'|K.rt  ..f  tlio  Fmi.li  .an.puii.'n  at  1M,U-.1 
likewise  nfers  U>  Minilar  cases,  KKsteiu  '  was  ..lie  of  ll,e  tirst  lo  eall  allen- 
tinti  t.,  this  intereMiiii:  cotMiilicaliuii.  His  pal  lent  exlnlatea  hnll.ar  distur- 
Imne..  of  siH-eel.  an.l  ataxia,  wiliiont  anv  other  impairment  of  motor  |H.«er 
or  sensation.  Analomie  .■xaminalioii  ili.selose.l  insular  ^'ray  .kreneratmn  of 
tile  spinal  eoril  ami  the  hulli. 

Cases  ..f  -i.iiial  panilv-i-  of  (liilclli<i<"l  lia\e  l»'<'n  nuntioiK'*!  l>y  u 
miintiiT  of  wiitc  r<  as  of  rare  ..eeiiiTmce  in  the  coui-.'  of  or  toward  llie 
ei.,-..  of  the  attack  of  typhoid  fever.  Tlu' earli.'r  v]Hn1>  are  not  liax^ 
i,p,,M  anatomic  examination.'  Itecently  Kichardicr  '  lias  piil.li-he<l  a 
report  of -2  ca-es  ..f  this  Uiiid.  whicli.  however,  I  liave  not  yet  heeii  aide 
to  olitaiii  ill  the  oriL'inal. 

In  coneliidin-  this  -.■ction.a  few  wor.i-  may  Le  -tate<l  with  re^ninl  to 
the  state  of'  \Uv  ivllexe-  Im  ca-e-  of  typhoid  fr\  er.  In  ( iermaiiy  only 
Striimpell  has  hitherto  di-cii-etl  them,  while  French  iiivesti^ratoi.i 
aj)!>i-ar  to  have  mad.'  e\lcii-ive  ol.-crvatioii-.  I  have  pers-mally  made 
>.,ni<'  ol.-ervatioii>  at  various  times  and  in  an  irre-ular  manner,  l.iit 
wliieh,  neverthelc",  have  yiel.led  .rrtain  data.  I-ike  Striimpell.  I  have 
found  in  severe  cax-  in  iialient-  who  were  irrc:itly  reduced,  toward  the 
end  of  the  I'ever  ..r  diiriiiL^  convaleMcnce,  marked  exa^r^'ciation  of  the 
patellar  tendop-rellexes.  Often  I  was  even  aMc  to  elicit  sli^rjn  or  even 
a  mark.Hl  .\.liilles  lendon-retlcx.  In  mild  and  iiKMl.i-ately  M'vere  cases 
the  jiatellar  teiidoii-reth'X  is  ex-ei'diiiirly  varialile  at  the  liei^dit  of  the 
di-ea-e.  Karelv  it  is  entirely  waiitin>r,  but  in  the  ^rreat  majority  of 
ea>es  it  remains  normal  or  is  s(,mewhat  enfeelilc<l.  Towartl  the  end  ot 
the  attack  and  <luriii>r  the  piTiml  of  convalescence,  even  in  mild  ciises, 
1    have  ohserved  now  and  apiin   moderate  exair^reratioii  of  the  reflexes. 

'  M.iuii.ri'il  i"  tlirir  li'\l-l k-, 

''  \',.rlr.',i,ii'i<ti   iiliir  Krivil.lintni  ili'^  /^(,-ArH/»(i/-A.s.  GiTiiiiiii  trun^lution  liv  Wi'iss, 
Vii'nriii,  ls'.i4. 

'  l>riit-<rh.  Arrfi.  f.  I.l'iir   M.f  .   Itil.  ix.  iohI  \. 

•  .'^cc,  fnr  ill>liiIi(M'.    HiMH-aikt.    I.rhrhu.-h  ■/■■,-  .\.ri-r,il:ni:,Uii-i/ni. 


Ml 


T/ii'.^f.  Piiri>,  iss.'i,  filed  I'V  .Miiric  \vlio  u|  ■ 


liiriisill"  te  liiivo  inude  no  f'.i 


iniliir 


obfervulicin. 


-XL^'jnt- 


•^^jr^f^m-L.^ 


1 

t^.r-^ 

* 

mi 

1 

m^ 


'SO 


r)rii"U>  1 1  \i  i: 


III  (liil.lnil  I  li:iM-  .il)-<i\.<l  (  111!  1  111.  iiic  Ml  all. I  :ili-.  li.  .  ..f  lli.  n  IliM- 
Willi    nlaliMly    ;.'n:il<  r    iV."! >    lliaii    in    a. lull-. 

General  Neuroses. — (li.'ica  iiiiii..i,  i"  \vlii.li  IMli.t  .ui.l  r.aiili.-^ 

!ia\.-  i:illi-<l  all.  iili.iii,  i-    r.inly  iiHiiliiuii.l   a-  a  -..|ii.l    ..t    l\|ili..i.l  lt\.r. 

I  lia\.-  |H  i--"iiall\  nl.-.i'\.-.l  a  »niiiaii.  lliirlv -..ii«  \.ar-.'l.l.  h  li..  a.  i|iiir.il 
SfV.Tc.  .linnilc  .li'T.  a  iiiiin.r  in  li  r  1\miiI\ -lillli  \.ar,  .lnini_'  .  .iii\  Ml.^.tii.'i' 
fr.iiii  l\|ili.ii.l  l'>'\.  I-.  I'll.-  lii>lMr\  r.laliiiL'  l.i  llii-  |i..lnl  ua.-  I.a.-f.l  ii|Kin  llir 
slaliiiiinl  .)!'  a  iii..>l  lni>lH.iilliy  |ili\^i(iaii.  wlm  liciili-.l  llir  wniiiaii  .lining: 
Iht  alla.k   .if  l\|ili..i.l    tiv.r.      I  liavtul"...  nliMrvcl   .linni.' l■lln.li^Kln^  in  •'> 

.liil.ir.ii    in    tin'    .■niir-c    .if  l\  [ilmiil    I'l-v.-r.       Ii ■    .  a.-..  « lii.li    .lr\  fl.i|ic.l 

.liiriiiL'  .■..nvalfx-.iio  Inmi  an  iiilaik  .if  uplii'lil  li\tr  |.ri.|.iiii:i>l  >'vcr 
six  wi-iks.  ill.'  .■iiii'lili.in  wa.-  prin.  i|.allv  .me  ..I  miilal.  inl  .licrii.'  Ih  ilcliint:. 
riM'.iv.rx  tr.iiii  wlii.li  l.-ik  |.la. .  in  llif  '■.nir-i'  nl  >i\  w..  U:-.  '1  lie  >.-..iiiii 
oliil.l,  in  vsli.im  llic  <liara.liri>lii  iwil.liini.'  M|i|.«Mrc.l  iliirini;  llic  lliinl  "><k 
1)1'  till'  alla.k  .if  fever.  rci'.iviTc.l  t".>  iin.l  a  liaif  ni.mllis  after  .'..iivalo.  .n.c. 
Witli  r.'irar.l  t.i  tlie  tliinl  eaw  I   have  im  tintli.r  n.ite>. 

In  -A  iHM'  at  the  .l.ilnis  ll..|ikin-  II  -|iilal  of  a  miiiiil'  w.iniaii  «liii  Im.l 
ha. I  .linmie  .li.ir.'a  f.>r  a  \.:ir  liefer.'  lli.  ■n-.i  ..f  ly|ili..i.l  f.  ver.  lliere  was  ii 
ili«a|i|iiaran.'.'  nf  llu'  .Imi-.i.'  iii.iv.iiuail-  .liiriiiL'  llie  lieiirlil  .it'  the  f.ver.  «itli 
a  ^.'ra.lual  r.turii  .liiriir.'  .■(invali>.-.-n.-e. 

(H'.itlier    Melir.i-i-,     ref.felie.'     IliaV      1h'     llia.l.      t.i     tlie    .icelirretiee    of 

panilv-i- aL'itaii-  (  r.«ii«'.likt  I.  I  lia\.'  iiei-.mally  .ili-.r\  ..I  tlii-  e.iiii|)ii- 
iiiti.iii  lull  <iii<-e,  ill  a  u.nnaii,  f.niy— i.\  y.ai-  ..j.l.  .i.ciirriiiL'  lat.'  (lining' 
ciiiivale-eiiiee,  all. I  then  |ier-i-tiiii:  wiih'int  .haiiL'e.  K\.i|il'tlialinii' 
{riiit.r  ha-  lieeii  iiieiili.iii.il  li\  \\  alij.  iil'ini:  a-  a  -e(|ii.l  (if  ty|ihiiiil  (.vcf. 
Kieiiii.ir-t  an. I  .ilhers  ha\i'  -■■.•ii  .liali.te-  in-iiii.hi-  .le.iir  in  .■.iiinc- 
ti.in  with  tviih.ii.l  f.ver.  1  have  |ier-iinall\  eii..iiiliteiv.l  ii.i  .a-e  'I 
citli.r  .•.iin|ili."itiiiii.  In  1  SS'.i,  ( iilm.y  .l.-.'iilie.|  a  -ii|ii.l  .if  t\|ili.>i(i 
fever  whi.h    he  eall.<l  "tli.'  ty|>h.ii.i  -|iiiie,"  an.!  wlii.li  h.'  r.uaf.ie.!  a-  a 

i)eri-|Hiii.i\  liti^.      (>-l.r    ha-    -in..-    r.|>.iite.l    a    Inr   ..f  .(iiit.'  similar 

case-,    iii.)-t    .if    whi.h    lie    nirai-.l-    a-   e\aiii|i!e-    <.f  a    |iaiiifnl    neiimsis, 
anal,  i^ri  HIS   to   tin-   iiainfiil    .■.ui.liii.Hi    in.t  with    in    tin    "  liy -teiie   spine' 
aiui  the  •' i-aiiwav  s|)iii.'."      It  ii-nally  .•.mies  .m  .iiiriiii:  e.iiivales.-eiiee  in 
lieiimtie  indiviiiiial-,  ami  the    -li'_'ht.-t  h.  iLliiii:  m.iveliielits  iif  the    hack 
inav  elicit  I'xpressi.in-  nf  the  ni.ist  a.iit.'  pain. 

I^esions  of  the  Peripheral  Nerves.— Th.'  peri|ilieral  nerves, 
csp>ciallv  tli.ise  (if  -piiial  .iiiL'in,  appear  in  li.'  iiiv.il\.-<l  iii.ire  fre(|iieiitly 
tiiaii  the  -pilial  oifd.  As  in  dtjier- infe.li.Hi-  di-ease-,  the  e..ii(liti..li  is 
il-iiaiiv  .111.'  (if  neiiriti-,  which  may  manif.-t  it-.ll'  a-  an  alr.i]>liic  paiiil- 
v,U  ,,f'  certain  iiiiiselcs,  mii-el.-iri'>ni)s,  .>r  an  entire  extfetniiy  ,  or  even 
as  a  jiarapletria,  or,  in  -till  wider  (li-triliiiti.iii.  witli  the  clinical  pietili-e 
of  |>r(iii(iiinec(l   |).ily  iieiii  itis. 

r..itli  the  .linical  and  th.- anat.iniic  kiiowledj:.'  ..f  neuritis  itself,  and 
the    .iliservation    .if  it-    oeciirreiiee    in    the    c.nir-e  of  typhoid    fever,  are 


■MH 


m^w  ^€m 


■'«iii^.&iiagi£tr»r»i^^ 


SYMI'loMS  .\\1>  (  iiMri.lCMIoSS. 


l!.sl 


-till    .oiMiuniliv.ly    nvciil.      It    i-    )>.— il.l.',  Ii"«<v.t,  a-;   lia-  Imvii    \>\;- 

viuii-lv  iiilimal.-.l,  that  a  I'.w  .a-.-   ..f  |paial\ -i-   -iipi -.1    I"   Im'  of 

-plnal  .>iit.'iii  u.iv  ariiially  dur  lo  ii.iirili-.  In  llii-  .•alr^MV  1.. i.,,^' 
tlir  I  a-.-  ..r  atiMplii.-  |iaral_v-i-  in  wlil.li  llic  mii-.i  -  (  \liiliii.'<l  a  ivac  ti..ii 
,,r  ,l,-.M,nilion  :ui(l  lo->  ..t'  (l.vliic  iiiilal.ililv,  uitli  Icndc  iii.—  mm 
|.iv"iiiv.  a  — Nia!..l  Willi  •.iilij.rlivf  aii.l  nl,|nli\  <■  ,li-tmlKni.-,..  nC  -.11- 
siliMii,  aii.l  ill  wlii.h,  .A.'M  ill  a.lvaii.r.1  .a-r-.  muN  ,iv  ..r  man  rial 
i,„,,iuv,iii.tit    l."ik   i-larc.      l,.'V(l.ii   larly  rrf.Tiv.l  to  ilir   |.rol.ai.iiit y  n\ 

tin-  Mioiv  riv,|iiciil    o,viiiivii. r  iicriplKTal   luurili-   in  .a-.-- oi'  typlioul 

frv.r   in   tii-   1.00k   on    IHs,;im..  ,,(  thr  Sf.iHul  ( 'u-.l.      Nriiriiic  i.ar.ily-i> 

,„-,iir-  1,."  fiv,|n(iitly  at  tlir  li.  i-lil  "I"  iIk'  «li-.a~..  than  toXNani  it-  <•! 

aii.l  into  lair  conval.-.M  ii.'.'.  I  liavc  ol.-.Tvni  iifiintic  |.a.-alyM-  .,f  Ih.iIi 
lo\\vr  .■xtivniiti.-  .lev. lop  a-  lato  a-^  tlif  fAonly-iiiiitli  .lay  att.r  .1.  f.  ivcs- 
rcn...,  alnr  tlio  i.atimt  lia.l  alivady  iroit.Mi  .mt  of  l.f.1.  Sndi  latr  .«vnr- 
n'li.v  i-,  it  is  true,  -till  iiior.'  iiMial  alnr  ,li|.litli.Tia  tliaii  after  tyjiiioiil  f.v.r. 

I'aralvsis  duo  to  noiiriliri,  l,oili  wlicii  cxttMisivo  and  iiiou'  parliciilarly 
whoii  .iniini-.Tilied,  apiH'ars  to  involv.'  tlit-  lower  cxtri-iiiiti.'M  iiiori-  fiv- 
niifiitly  than  tlie  trunk  and  the  np|>er  exlremilies  when  it  iK-eurs  in  ea-t's  of 
tvphoid  fever.  Ainoiii:  inv  .•a«>.-  are  J  of  panilvsi-  m  the  |KToiieal  nirioi,, 
nnd  1  each  of  paralysis  of  ilie  uddiietors  -f  the  tliii'h  and  ol  ih.'  .pia.lnee|«4. 
Taralvsis  of  the  latter  hits  l«en  nieiitione.i  also  hy  KratllKhniL','  as  well  iia 
hv  Notlmairel  aii.l  Siirnmv.'  Of  other  forms  of  iieiiritie  paralysis,  that  of 
the  loiii;  MUiseles  of  the  I'.a.k,  the  >errntns  1  Euleiihiirir  1.  iis  well  as  that  of 
the   iiliiiir  and  the  iiie.lian,  li;us   U-en   reeorded   in  the   literature. 


Arnoufi  the  eases  ot'  para| 
hv  Notlmairel  deserve  meiitioi 


111  an  a 


lillt.      I   havi-   personallv  seen   neiiri 


ia  of  the  lower  extremities,  4  eases  re|i<irled 

Alexander'  has  also  re|M)rted  such  u  ea,<e 

tie   paralysis  of  holh  lower  ex- 


tremities 111  a  l)OV,  eiL' 


of  a  mild  atla< 

i.t' 


■k   of    t 


yi 


tit    years  old.  which  lieL'an  as  early  ils  the  se.'ond  week 
feyer.  and  from  which    recoyery  ensueil   aller  a 


nratioii  ot  six  moiit 


hs.     Cadet  <le  ( ;a.s>icoiirt  '  an<l  Henoch  '  liac'  prev 


lislv 


culled   attention 


to  tl 


lis  comi>lication    dnrintr   <hi 


hlh 1.      Filially    the  fact 


U 


may  l)e  nu 


r 


nara  lysis 


iilioneil  that  neiiritic  proces.ses  may  deyelop  al.-o  without  atropine 
it  wholly  without    clinical   iiiaiiif. 'Stations,  as    liuld 


in    fact,   almosl 


,d    Henihanlt"  and  recently  i'itri 


id  Vaillard   liaye  ilemoiist rated  ana- 


tomically. 


Seiisdfv  (li-tiirhaiK 


till'  jiart  of  the  s])inal   nerves  are  nut  ipiitc 


.s()    fiviiiieiit    as    (he    motor    paralys 


("lit 


iiieoii-   anestlie-ia 


iiieii- 


tioneil  liv  niielielilie 


Crie— iiiirer,"  (inliler,'  ami  snh-cipienlly  liy  lumier- 


Oll^' 


otlier    writer^,  a<,  for    in-tanee 


Kratl't-Kliiiiir '"  ami  Biiiiniii 


It 


lU-'.hitrlilmiqi'n 


1. 1  Sf'd/irn  iili.-i 


.I'W,, 


'  .ln-/i.   i/t'i 


,/.■  M,,l  .   1 


«  TrnUin  rlir.  c/rs 


» r.< 


.  rit. 


"  ••  Klini? 
Mfd.,  Bd.  iii. 


<-li(.    I'...,.li:u'ti 


Ki;.-,. 

T 

1. 

,/.•  r 

ml 

itHi'f'. 

lSS-_ 

'  D. 

1', 
'11 

Ir.'tr 

ftit. 

niiii: 

nlicr 

Al.d 

'.^.  ISTI. 

[),,,/s,-l,       ,11 


T.  ii. 
l.^iilf.  18r,i 


■./,  HV/,.,  \mi. 

'  (:/,„nt,-AnnaleP.  18!>2. 
«  /,,..-,  rit. 
1"  /,..,-.  nf. 


iiiniiltyphii-."    Dr,ifyi-/i.    An-/i 


f.    kli 


V-' 


f         i! 


; 


^^t-ww^m 


MICROCOPY    RESOIUTION    TEST    CHART 

ANSI  and  ISO  IE5T  CHART  No    2 


I.I 


t~  III il      i  2.5 


U    il 


32 


111= 
l"       lllll^ 


1.8 


1-25    III  1.4     mil  1.6 


A     APPLIED  \hMGE     Inc 


■:6J    482  -  030C  -  Phofie 
■61   288  -  5989  -  Fo« 


282 


ryriKiii'  n:vi:n. 


M 


'I': 


1 


(J3=:g 


lia>  (>('<'iirrc<l  al.-i>  in  ^(■\(^:^l  iii>tan(('>  in  my  i'.\|H'rifiii'c,  iin<l  is  niani- 
i'otcd  in  ]iart  liv  ini|)ainii(nt  or  ciiniiilitc  alxilitidii  dt"  sensation  tlirmijili- 
(tnt  tile  <li>lriliuliiiii  uf  certain  ncrvi-  or  in  i|nitf  <ii('iiinMriii(Ki  ai'tas  n*' 
tlic  >i<in.  S>  fill-  a>  I  <an  recall,  the  sariniis  iiirins  oC  >cnsati<iii  wtrc 
eiiiiallv  ini|iaii'e<l.  (  aso  of  cntanc<p|i>  anestliesia,  ~ncli  a>  arc  (iliscvved 
tliirini^  convaloeencc,  c-|)ecially  in  adiill  teiualo.  invoUinL^  c.\tcn>ivo 
ai'ea.~,  witliout  hein^^  cimlincd  t"  deliniti'  iicrvc-area~,  a|i|ieai'  In  hclniifr  to 
the  gnin|>  uf  livsteric  disorders,  which  are  nut  rarely  encountered  in 
the   SI  'Men(f   ot    tvplioid    ti'M'r. 

\^^j\  t're(|iient  than  the  -iTn|ile  deraiiL;'eiiieiit~  of  Mii^ation,  and 
especially  n'e  \('.\atioii>,  arc  the  neiiraliria-.  Anioiitr  thoe,  neuralgic 
])ains  in  tlu'  toes  and  the  heel,  and  al>o  in  the  reniaiiiinir  ]iortioiis  of  the 
sole  ol'  the  li)ot,  have  occiii'iid  in  my  e:.|.erii'ncc  with  |iartieular  frc- 
qnencv.  ( 'om|iaratively  rare  at  the  height  of  the  disease,  they  are 
likclv  to  a;)i>car  c-peeially  dnring  the  ~tage  of  defcrveseeiiee  and  the 
first  j>ai't  of  the  period  of  coin :.ie--i ciice.  to  the  great  distre-s  of  t!ie 
j)atieiit  and  also  of  the  phy-ician.  to  whom  the  ol)>tinaey  of  the  dis- 
order soon  heci.me-  a|ii>arcnt.  At  times  the  patient,  nnder  siieh  eircnni- 
stance-,  is  nnahle  to  rest  ihc  lliot  npon  the  heel,  -o  that  this  nuisl  he 
])lae:ii  njion  a  concave  -urfaec  ;  while  at  other  times  the  hed-clothing 
nin>t  he  >np|iorted  liv  mcaii>  of  hoop-,  in  onler  that  it  may  not  exert 
]ii-c->ure  npon  the  painfid  toes.  {•"ortnnately,  the  )iains  eventnally  dis- 
a|>j>car,  generally  withoiii  ^|M(ial  intervention.  Xcverthcless,  I  iiave 
e.Nccptionallv  oliscrvcd  them  to  per>i^t  for  a  con>ider:ililc  ])criod  of  time, 
in  one  instanc<  toi-  a  year  and  a  hall',  and  in  another  tor  more  than  two 
vears.      In  hoth  in-tanecs  neuralgia  of  the  heel  was  present. 

\enralgia  <if  the  -ole  of  the  foot  ami  of  the  toes  ha<  liceii  long  and 
penelidiv  known.  Among  tho>e  who  jrave  ret'erred  to  it  are  l)neheck,' 
Liclici'mci-ter  ami  Ilagc  iiliach.-'  .Filrgcn^eIl,'  Xotlniagci,*  Frit/,'  and 
Krall't-I-'.liing."  It  i>  mentioned  also  in  the  Sdiiilint/  Hi/Kirt  ';/'  (lie 
(uriiKiii  Ariiiiis  fi„  IS'iO-H.  Sciatica  ajipears  to  he  much  loss 
common  (llcnedikt,  N'otlmagel).  I  have  never  cncoimtered  it.  I  have 
ol)>crv<'d  ill  a  woman,  foiI\-one  years  old,  who  had  a  neurotic  tendency, 
Jill  extensive,  severe  neuralgia  in  the  (li>tril)iitioii  of  the  hrai'hial  ])le.\iis, 
in  association  with  persistent  lihrillary  mn^ciilar  contractions  in  the  del- 
toid and  the  trieep-,  Imt  without  atrophic  paralysis.  IJiroveiy  ensued 
in  the  cour-e  ot'  three  months. 

I  have  ol)-er\('d  intcrco-tal  neuralgia  in  'J  ca-e-.  in  I  asMicjated  with 
herpes  /osier;  oeci|iital  neuralgia  in  ■'!  ea~e-,  the  tir-i  ilevelopiiig  during 

I  z.,,,.,  ,.,7.  •  I.,.-.  .-.',  ■'  /.->■    ■■<!.  '  I.,^.\  ,■>/.  '  /....,-.  rit. 

«  Kliiil-r/H-  Sfii'lirn   ,,l,rr  ,1,    li-'/i'iinil iilhl  -/.  -   Al»i  .,„,i,,ilh/jj,lif. 


SYMPTOMS  AM>   COMriJC.lTloy'^- 


283 


the  n,.ri.«l  oi-  irn.j:ulur  ,..,n,...ratun.,  an.l   .he  o.Iut   twu  ,h,nM^  ronva- 
hJnro.      lt.r„v..rv  onMU.l  h,  all  :!  .ax-,  in   1 ,  it  i>  trne,  H.ly  at,..,'  .ho 
la„<o  nf  live  n.-m.h-,  l.u.    in   .he  ...Im'.'  "-i   i"   tl'-  .■-.uoe  ..t   a  t.w  weeks, 
x'.nrahria   in    .he  .li..ril>n.i.m   -f    .he   hnnl.ar    and    .ho  .Tural   n^  vvs, 
whieh   has  heen   nu.,.tiun,.i   in   .he  li.era.nre,    •    have   no.   .. h.e.ve.l 

Th..  ^.ate  of  .he  sen-orv  .vfhxe.   in  .he  eonrso  of  typhoMJ   ivyrv  luui 
hither,o  heen  l.n.  li..le  inves.i^a...!.      The  li.era.nre  eon.ain-  hn.  sean.y 
rot;.n.neo    .o    .he    <nl.iee.,    an.l    mv    own    oh-erva.ions    al.o    are    iew. 
Aeeonlin^  .o   .he-e.  .he   <ensory  retlexe.   appear  .o   he  ^e.>en.lly    .nn.h 
.lin.inishe<l    aurin,^    p.otonn.l    ••on.a,    while    in    .nod-raU.    an.!    n,    nnl, 
,..,sos  thov  loss  eonui.onlv  exhihit  al.era.ion-.      I    Lave  tre.p.en.ly  lound 
their.    lu.rmal,   or  .liniinishe.l    ...ther   than    inerease.l,    even    n.    e  s.s  of 
modera.o  -^everitv   showin.L'  marked   tremor. 

rn.l.mh.edlv:   eo,.-i.lena.le    in.Tea^.'    in    .he    sensory    .vdex    ae-.v.  y 
oe..asionallv  oe^n-'s  and  .his  ,nay  ,.e.-M-.  ti.r  week<  and  n>on.h-  at.er  .he 
attaek  of  .v,>hoid  l^ver,  espeeially  in  the   lower  ,.x.n.n.i.,e>,  .he  soles  of 
the  foot,  an.l  the  ah.lominal  wall.      In  son.e  pa.ien.s  .he  fr.e..on  ot   .he 
clothinjx   in   walking,   the   wearing  of  woolen   ^..K.kh.^rs  and   the   hke, 
.ivo  rise  to  a..  an,.ovinfr  s,.nse  of  .ieklin^.      In  1  .a-e  under  iny  oh.er- 
;ation,oe..nrrin,^inan.an   who  was  hi.d.ly   n.rvons  hefo.v  .ho  at.aek 
of  tvphoid    fbve,-,    the,-e   persistcnl   sneh   a    de^r-vo   of  i:o.,oml   .....aneous 

hvpen-.he-ia  of  the  lower  half  of  the  hody.  wi.h  J.nne.ato  an.-.h.Ma 
,„.l  oxa-.>ra.ion  of  th,.  plan.ar,  ere-nasfri.',  an.l   ah.lomn.al   nH.x.-s, 
that  the  ption.    for  a  lon^^  .in.o  eon.d  hv  pernn....l  .o  walk  only  when 

a  olosoly   applio<l   silk   prote<..ive  whi.'h  .lid   not   s..,-atoh   .Iw  skn.   was 
plaood  hoiiea.h  th.'  .m.er  ol...liiii:jr. 

Diseases  of  the  Ear.'— Th..  ..riran  of  special  s,mso  l.y  far  most 

froq.iontlv  inv..lv.>.l  in  .1...  ••onrso  of  (yphoi.l  f.'ver  is  th..  .'a.-.      Am.,n- 
l-M-J  .-..-OS  of  tvph..i.l  f..v,.r  analyze,!  hy  15e/...l.lr  impairm..n.  ..t  hearn.fr 
o.^.,.rr..d  in  4  p.r  eont.  in  .1...  ..onr.o  ..f  th..  dis..a-e.      Other  anri-..  als,> 

emphasize  .ho  fn..inen..v  of  .his  .....nrr.........      Tluw  Bin-knor-^  stafs  that 

in  1  S  per  <.ont.  ..f  all  .■as..s  prosontin.ir  impairnu.nt  of  lu.armfr,  lio  was 
ahlo  t.>  .l...ormi.u.  tvph..i.l  fever  as  the  <.auso  .,f  th..  .li.or.l..r  ;  while 
Zaufal  fon,..l  a  similar  ..ti..l..j.ne  fa...or  in  0.7  ]h-v  .vn..,  an.l  Kranu.r 
in  "2.0  JKT  ooiit.,  of  their  eases. 

.See   \foo,,  S..hwurt«.-s   Ilnn,/h„r>,   ,/,    < ,/,rr„).y,lk.n„/r.   15,1.   i.      S.lnvMr./^.   -Kr- 

TuuM.ri,.  ■  ...r.,  Arr/../.  <>h,-r„h..  WA  ami  IW.T.      .\..at..nn,.  r..f.T,-nr..^  ,..„  l.<  tou„.l 

in  th..  pui.iT  .■!'  ('.  v..  Hoffiniin,  /"••■  <•''  ,     ■    ,  ,        l 

"  'r,.l„.rai..  Krkr:u,kun.ona..s.i,.),..n,r.u„-  l...  l!,..,.y,,l,u^.  •  A,:->.    r  nl.rmh., 

:>  ..BHtra-e/AirStatistikderOlirkrankli.-iton.-  An-I..f.   Uhrn.h..   IW.  XX. 


I 


•>s  I 


ryi'iinii'  ii:vi:j;. 


J 


'I'lic  ili-Mi-il(  i~  lit'  iKaiiiiir  lliii-  liir  111  "-crxtxl  arr  iiKi-t  \  arialilc  wiili 
rrlci-iinr  lo  ilicir  -lal  ami  iharaclrr.  Willi  rr^iard  in  tlir  cMci'iKi!  car 
aixl  tlir  au'lili>r\  canal,  tlic  i-arc  ca-c-  nl'  caiiurcnc  nl'  the  auricle  arc  id 
lie  Kdriic  ill  iiiiiiili|i.  \>'iS).  I'crio^titi-  lit'  tlic  cMcriial  aiiditiiry  canal 
ami  |M  il'ii-ati.'ii  ul'  :ili-c<--c-  ut'  llic  |iariiliil  ;jlaii(l  iiiln  llic  carlilaL:imiii< 
iK.rlioii  c  '  tlic  canal  arc  inure  l're(|iieiii.  l''iiriiiicuin-i-  dt'  the  cxleriial 
aiiililcirv  canal  i-  al-n  lre(|iieiill\'  inenliuiicd.  1  lia\i'  Mli-er\cil  it  in  a 
niiinlier  111'  in-Iancc-  a-  uni-  ul'  llic 'nianil'olali.iii--  nl'  innlti|ile  t'liriiiicii- 
lii-i>  ul'  tlic  -kin  ilnriiiiT  ciin\alc.-ccnce  rrmii  ly|>liiiiil  lex  <  i\ 

Aniiinir  the  ili-unler-  ut'  ilie  inieinal  ear  a  (li-iiiieiiuii  i>  jreiierally 
made  lictwccii  pnrciv  iier\uii>  ur  t'liiictiupal  ili-unlcr-  ami  tlm^e  (Icpciul- 
cnt  niiiiii  uriianic  eair-c-.  'I'lic  |)iirely  iinctiunal  (li-nrdcrs  are  liy  no 
mean-  rare.  A  purtiuii  ut' tliese  make  their  a|)|iearaiiec  a;  the  lictrinninfj 
(if  the  attack,  ami  while  they  are  |)us>ilily  le>-  euii-|)iciiuiis  at  the  heiirht 
of  the  ili-ca-e,  it  is  unlv  lieeaii^e  the  |)rut'unnilly  <ii|iuruM'  patients  make 
nil  eiini)ilaint.  Aiiiunu'  tlic>e  (li~turt>aiicc-  is  tu  lie  inchiijed  especially 
the  cxtrcniclv  aniiu\  iiiir.  -iil)jceti\-c  sensitiuii  ut'-unnil  as  ut"  ruariii^'-  and 
riii^'inLT,  which  is  ut'teii  pnsent  diiriii).'-  the  first  pcriud  <>■'  the  di-ca>e. 
I'rulialiK'  the  alniu-t  characteristic  iiii|iairment  of  hearing'-  at  the  heiirlit 
of  the  disease  is  al-u  in  iiianv  eases  due  Milely  to  ne'-vuii-  di-tiirliances. 
At  lea-t,  it  i-  iiftcn  inipus>il>le  to  demun^tl■;ltc  any  causative  Ic-iun  with 
niu-i  thuriiuudi  inM^tiiratiun.  'I'he  priijrnu-i,-  ut'  the-e  di>iirdcr^  is  tavur- 
alile.  Thev  ilisi|iiiear  wiih  >nl>-iilcnce  lA'  the  fev<  r,  ur  at  any  rate  with 
the  end  of  ciiiivale>eciice.  While  t'urmerly  the  cause-  ii\'  these  distiir- 
lianccs  were  thuiiLdit  to  cuii-i-t  in  liy|>ereniia  ur  anemia  i4'  the  liraiii  and 
its  niciiiliraiic-,  ur  cxeii  ni'  certain  parts  ,,{'  the  middle  ear  it-elf,  at  the 
present  dav  the  actiun  of  tuxins  n|)iin  the  |iarts  in  i|iic>tiun  is  |irii|ierly 
made  re>piin>iMc. 

The  di-iinlers  i>\'  the  middle  ear  de])endeiit  u]iun  anatumie  le-iuiis  arc 
referalilc  ])rineipally  to  exteii-iun  of  intlammatury  proeesM-  from  the 
structures  of  the  na-upliaryn\  thruiiLdi  the  Ku^taehiaii  tiilie  tu  the 
middle  oar.  Nut  rarely  iiiiicupurulcut  int'cctiuiis  matter  e;aiii>  cntnincp 
meilianicallv  to  the  cavity  of  the  tympanum.  The  |)ii--iliility  ut  dis- 
M'lninatiun  uf  excitant-  of  intiammatiun  fnun  reinut,'  m^rans  and  their 
luilL'inent  ill  the  ear  i-  pml lal ily  uf  -iiliurdiiiatc -iL''nili<-anee.  The  iniero- 
urL''aui-ms  of  ctiulotric  .-ii;iiitieauec  in  all  tlie-e  intlanimatory  ]iriice"es 
iiave  nut  vet  liecii  aile((Uately  detcrmiiicd.  K-pceially  it  has  imt  yet 
hecii  mail<>  out  to  what  extent  the  iiacillus  of  Elierth  itself  plays  a  part 
in  this  connection. 

The  coui-e  of  the  aH'cctiuii-  of  the  middle  ear  varies  hetweeii  the 
mildest    ea-c-   and    thii>e    which    are   the   mo>t    severe   and    are  directly 


,S)  l//'/V/l/.V  AM)   (  OMl'I.I'ATIOSS. 


2s.: 


(iMii'.a'niiK  or  MIC  MitcMilnl  witli  ><i|iii  he  wliidi  ii(rsi>t  tliriniL^linUt  tlio 
ivst  lit'  liti'.  I'lir  iii-iaiicr,  |i,iriiliiit  :-iiiii~-llii(iiiilMi--i-- (ir  [Krin-liti-  and 
carirs  of  till'  |H'lnni-  Ihihc  may  <lcv(lii|i.  I'lirtunalcly,  tlic.-i'  ]iript^Mii(l 
(li-tiii'l>aii<(-  arc  tiir  lc-~  ((iriiiiioii  in  tlic  <<iiir-c  nt'  iy|iliiiicl  tcvir  tliati 
In  some  otiicr  iiitcctioiis  ili-cascs,  a^,  i'or  in-tancc,  -cai'lct  I'cvcr  and 
(lijilitlicria.  I''ar  mm-c  tVc(|Mcnt  arc  the  milder  di-iniliaii<-cs  tliat  arc 
readilv  ovcrlooUed  in  tlieir  inri|iiciicy  nnlc->  llic  jdiysician  examines  tiie 
prot'oimdiv  soporo-e  jialient  lVe(|nenfly  anil  llioronuiily,  and  wliieli  a.'e 
ri'coLMii/eil  only  atiei'  they  iiavc  ^iven  rise  to  sii|(|>nrativc  intlanima- 
tion  of  the  niid<lle  ear,  with  iierforation  of  the  dinii'i-Tnemliranc  and 
otorrhea.  In  addition  to  intlaininalory  le.-ioiis  of  the  inid<lle  ear.  henior- 
vhaircs  into  the  cochlea  and  the  vestihnle  have  he^eii  ol.-crved  a.-  the 
cause  of  severe,  and  at  times  permanent,  imiiairmeni  of  hearinfr. 
MiM>s'  also  mention.-.  >mall-<'ell  iiitiltration  of  the  nieml>ranons  lahy- 
riuth. 

Disorders  of  the  Byes.- — Thc-e  are,  on  the  whole,  r.ire  in  ea.-es 
of  tvphoid  t'ever  ;  at  any  rate,  they  are  miieli  less  eonimon  than  di-eases 
of  the  ear.  ( iantrrenc  of  tiie  tissnes  has  cxec|)tionally  heeli  ol^erved 
in  the  imiiic<liate  vicinity  of  the  eyes  and  of  the  lids,  ami  has  lieeii 
attriliiited  to  eiidartcriti-  aiul  thromtio-is  of  the  external  I'arotid  artery 
and  its  hranche-  (|>.  lUS).  True  noma  eoni]ilieatiiiLr  typhoid  fever  is 
also  ineiitioiud  by  earlier  writers  as  a  caiise  for  e.xteiisive  destruction  of 
the  eyelids. 

I'aralvsi*  of  the  extra-neular  muscles  occurs  most  comnioidy  duriiiir 
coiivalcscenct'.  Knies  liclicxes  that  certain  varieties  ot'  these  c\tra- 
oenlar  paralv^es  ;ire  tincle.ir  in  oriiu^in  and  are  to  lie  attrilintcd  to  a 
chronic  iiepliriti>.  I'nilateral  and  liilateral  ptosis  lias  lieeii  oliserved 
(Xotlmairel,  IIcuocU).  Cases  occiirrinir  diu'injf  the  hei<.dit  of  the  fever 
are  very  rare  in  the  aliscuce  of  intracranial  complications.  Ptosis  and 
nliducius  palsy  have  lieeu  recorded  in  the  third  week  of  the  disease  liy 
Xotlmairel.  In  a  case  at  the  .Folms  Hopkins  Hos]iital  K'lilomoto,- 
jiaresis  of  the  left  eye  developed  on  the  eiirhtli  dav  of  the  disease.  In 
this  case  there  was  |iaralvsis  of  lioth  intra-ocnlar  and  extra-ocniar 
ninscles,  .nnd  the  condition  was  jirolialilv  due  to  a  sliirlit  local  inenin- 
iritis.      In  cliildrcu   symjitoins  of  ineniniritis  and  stralii-mus  may  occur 

'  /,...-,  rit. 

tler\in<jrn  iihil  Krnnklifitrn  itf^  SeliKninnrn.  Lcip'^ic.  187":  aiiil  Knii'».  Dir  Hr:ir/ii{npni 
tft's  Si^h(irf]a}tgs  t/w/  srinrr  F,t'krniikunqi')t  9it  tirv  uhriijrn  Kmyikhrit*  ti  </>'■•*  Kurprrs  t(tt<l 
s,:iiirr  (>ri/n>if.  Wil'^ll:llll'll.  IS'.i*.  A  Ue.  il,-  Si-liwrinitz.  cliiiptPr  "ii  ■■  I  Iculiir  ('■niiiili- 
<'iitic>n~  in  T/ir  Sur-ii.-n/  <^,!„pli,-ntin„ii  ,niil  Seijurls  <■/  Ttjp/itiid  Fever  liy  Kei'ii,  rhila., 
ls;i«.  I'h^la.  M,;/.  J..,,,-..  Mari'h  ^,.  I'.'(K). 


il 


TYi'iKni)  ri:vi:ii. 


"^^ 


f  .)-, 


early,  hut  it  i-  (jii(-.li..nal,l,.  -vlntlicr  tliry  aiv  a-iM-iattHl  witii  ;i  tnic 
iiM'iiiiiLical  iiitiai    nation. 

I'aral_v.-i>  (]f  :  ,,■  intra-iM'iiJar  inii-clt>  i>   ai.-o    -f    (■imiiiKin   (luring: 

.•oiivalr-reiHc.  l',.r-t,r.  will,  wiioni  K  iiic- airivc-.  coiiMdcrs  tlj,.  |,:i,-al- 
\H~  of  :irc,,iiiino(iati(.ii  and  niydriaM.- a~  (—^cntially  part  iiianiti-tations 
<.t'  the  urnci-al  cxlian-tinn  ;  liir  ic-^  fiv.|ncntly  tju-y  arc  due  to  .■iivuin- 
.-(•rilird  ili^raM'  of  x\\r  anictcd  ii(rv(-|iatli:-. 

Arnonu  tlir  <lian-(-  in  tlir  cychali  it^'lt',  conjnnctix  ili<  -lionld  first 
!'<•  nimiioiu'd.  A  .ataiTJial  (nrni  -if  conjiMictivitis  occm-.s  trc.|iicntiy  in 
<i(i  I'ly  -o|M,i-o-c  pati..ni>  dnrinjx  llic  Tel. rile  iM-riod,  I,ut  l.y  no  means  so 
riv,|ii,.nlly  a-  lyi.lni-  leserand  -niall-|.o\,  ,,r  even  tneasle-.  lVol,al,!v 
tlii- eonjun.'tiviti-  i~  not  ,|,e,.ili,,  l,ni  i-  d,.|,endent  upon  or  llivoivd  l,y 
''"'    '^"■'    'I':"    tl"'   'I'lll    I'alieni  \vinl^-    in(re,|nently  and    elose>   |li^   eyes 

inilidtictly    and     |M,-HMy    ai>o    l,y    il„.    ,iinn'ni-lied    seen'li f  tears. 

Dnrin^' <'onvale-eenee.  and  s,,nietini,-  in  llie  later  .Ma<:"-  of  tlie  disea-e, 
a  irne  pldyetennlar  eonjunetivitis  nun-  appear.  A  plilyetennle  niav 
liieakdoun  and  f.i'in  an  ulcer,  or  witliont  tliis  oriiriii  ulcerative  keratitis 
may  ariM^.  TIicm-  ul-vr-  arc  rarely  >o  lar-e  as  to  (.dve  ri-c  to  extensive 
Icid^oma  an<l  con-idcraldc   impairment   of  vi-ion.      'I'rne   keratomalaeia, 

wliieh  wa-  early  deM-rilied   hy   Ti -.,.an,   i^,  fortunately,  an  extrenielv 

rare  inanifesiation  of  pnpfound  tjiarantie  or  -eptie  condition-  (see  mv 
own  ca-e,  pp.  L'lil  and  -JUl').  Aecordin,!.'  to  Knic-,  iritis,  cyclitis, 
•  ■lioroiiliti-,  and  cliorioretiniti-  also  occur;  lcs~  coniinonly,  liowevcr,  than 
in  other  infectious  di-i'a-c-^,  a-,  for  iu-tance.  relapsinjr  fever.  Tiiev 
may  ::ive  ri-e  to  permanent  profound  impairment  of  vision,  as  the  eases 
of    .\rens  .and  'I'rejat.  cited  hv  Kiiicv,  -ho\\ . 

'l"hou;:h  extri'mcly  rare,  the  tran-itory  and  the  permanent  f  .rnis  of 
amauro<is  are  worthy  of  mention.  The  trau~itorv  form-,  whose  nature 
ami  eau-e-  have  not  hceii  adei|iiately  studied,  occur  almost  solclv 
ill  yoiuh  and  childhood  (  Khcrtli.  Xairel,  Fn'minau,  F.'.rster).  I  have 
per-onally  oli-|.rvcd  -ndi  a  case  devck.p  in  a  <:irl,  eleven  Years  old, 
without  demon.-trahle  Ic-ion  of  (he  eye-ground,  in  the  .•our-i'  of  ivphoid 
ncphrui-,  and  di-appear  within  seventy-two  hours  without  leavinir  a 
trace.  rreniia  mu-t  i>e  thouuhf  ,,f  ,.,,  the  cau-e  in  -uili  ea-es.  'J'lie 
pcr-i-teni  firm-  of  amauro-i>:,i  which  may  lie  either  unilateral  or  lulat- 

cral,  generally  de|icnd    upon   atrojihy  of  tl jitic  nerve.      The   -eat    of 

the  di-turhance  i-  to  lie  -oiinhi  either  in  the  hrain  or  in  the  optic  tract 
it-clt.  .\moni.f  the  cau-es  of  the  di-tnrhanecs  in  (|nc-tion,  hcmorrliau'-e 
and  -clcrotic  or  other  variety  of  f.eal  <li-ea-e  have  l.ccn  mentioned. 
I'rohaMy  menintdtic  exudates,  with  their  injiiriou-  secondarv  ett'ects, 
'  Tilt;  literatun-  i^  i;iMii  l.\   Fur.-ttT. 


r.iA7.i77o.v.<  IX  sy^n'T()Ms  .i.v/>  cornsi:.  2S7 

an-  :d.-i)  i>tte!i  upcnitivc,  :i>  Kiiie-  ami  F()r-tfr,  (.-](<'ri:i!!y,  !ia\c   |)niii!(il 

nut. 

optic  iifiiriti-  duriiiL'  tv|.lii]i(l  is  ii>iiall_v  a-,-iiciat(i|  with  tntiiiniriti'-. 
Ilowcvi  r,  ac'c<iriliii;.r  (,,  dc  Scliwciiiii/,  an  •i|>tic  ii(iiiiti>  may  (icciir 
\vlii<li  i~  ctitinly  uin'duiKrtcil  with  iiitnuTauiai  <iiin|ili('atiiiii~,  and 
i-  aiialiiiri'ii-  to  the  iiciii'iti-  m'cm'i'iiiL:  in  the  iicrvf-  il-cwhcrc  in  the 
hoilv. 

.\cnirdintr  tu  Hull,  fctinal  liciniin'haL:c'~  arc  nut  inlVci|iii'iit  dni-iiii^ 
the  hcii^ht  dl'  t_v|ili(iid  lever,  iHirii:  inu-t  eunirnon  alnmt  the  third  week. 
.V  pervei'teil  (jnalitv  ol'  the  liloud,  a  weakened  cundiliDn  nt'  the  likind- 
ve— el  walU,  111-  a  inieidltie  in\a-i(iii  I't'  the  Na^i'ular  e(iats  may  e-Kjiiaiu 
the-c  iK'iniirrhaLrt'-  (de  Sehweinit/). 

VARIATIONS  IN  SYMPTOMATOLOGY  AND  COURSE. 

The  character  and  the  severity  ut'  the  ccinr~c,  and  the  >ym|itiimatol(iirv, 
i)f  typhoid  i'cvcr  rcprcM'iit  the  e\|)ri-~inn  of  two  principal  f'aetnrs, 
namely,  the  iiumIc  nt'  actinn  nf  the  haeilhis  ot'  l^hcrth  upon  the  inxlv, 
particidarly  the  dcLrrec  ot'  its  virnlencc  ;  and  the  s|)<'ciid  conditions  of 
the  invaded  orjranism  itsclt.  I'hcsc  condition*  ai'c,  naturally,  I'XtrcmcIv 
varialile.  As  to  the  nature  of  these  coiiditioii-,  a  ])art  is  alreadv 
known,  at  least  "mpirically,  while  a  part  is  -till  entirely  undeterinined. 
.\inontr  the  more  important  detcriniiiinLT  conditions  ari',  first,  the  tiictors 
rclatin;,'  to  individual,  namely,  aire,  sex,  constitution,  occupation,  and 
mode  ot'  lit'e,  and  the  dcjxree  ot"  sii>ccptii)ility  and  power  of  reai'tion. 
Further,  of  importance  in  slia|)injr  the  cau-e  of  the  disea-c  arc  special 
proiidnciicc  of  ymptoms  on  the  part  of  individual  ortraiis  or  svstcms, 
and  the  not  uncommon  associated  activity  of  the  tvphoid-hiieilhis  with 
other  ])athoirenic  micro-orirani-ms.  In  addition  to  the  s|i(.(i;i|  eimdi- 
tions,  general  conditions  also  play  a  rod',  an<l  these  aH'ect  the  imli- 
vidiial  oidy  in  part,  hut  in  liir  irreater  dc<rree  influence  th(>  pre-icrvation, 
devclojimcnt,  dissemination,  and  the  dcirree  of  viridcnce  ot'  the  virus; 
these  arc  especially  the  local  conditions,  hahitations,  state  of  culti'.ation, 
ni(«Ies  of  interciiursc,  aixl  water-snjiply,  and,  linallv,  the  ireoirraphic 
situation,  eliinato,  and  season.  'I"he  varieti<'s  of  clinical  |)icture,  cour-e, 
and  termination  of  typhoid  fever  resultiiiL''  from  all  these  various 
inlluenccs  ;irc  so  diverse,  oft<'n  so  eoniplctelv  opposed,  and,  on  the 
other  hand,  at  times  so  runniiiir  tocrether,  that  anv  exhaustive  descrip- 
tion is  itnpossihlc.  Kvery  case,  llierefor(>,  is  different  from  cvcrv  other. 
and  any  ilcscrijition  can  serx'e  oidy  as  a  Lrniiie  in  the  tnid^t  of  this 
variahility,    and  determine    the    most    important    ])oints    of  view,      A 


n 


■  if 


'_>H,S 


TYriinii,  I  i:\i:i!. 


■.-•V:Vj 


g^ 


iiih-iiliraMi-  hliliilur  111'  i.ci  I-  iij  tlii-  iiilihfitiiii'  liiiSr  ;illi;nlv  licrli 
n  IriTicI    III    in    llif   cliniral    -criiuii. 

ll  will  lie  Im'-I  hi  ImhIii  ilif  (|r-iri|i|iiiii  willi  :i  ri  ril;il  o!'  lllr  -ilii|il(-l 
(•(iii(lili(iii- :  tlif  \  arii'lii-  nt'  l_\|iliiiiil  tr\ir  thai  n -nil  in  acccinlancr 
willi  llic  -(AtrilN  ami  llic  niililnc--  nl'  ihc  allack,  a-  well  a-  ihn-c 
vari<'lic-  ilr|Hni!inir  n|iori  tijc  iliiraliun  ul  ihcdi-ra-r  in  Lrrmi'al.  nr  nl' 
it-  liillrri'Ml  -lai;-)-.  It  may  lir  ciniilia-i/ril  in  aiKaiicc  that  -(Aifilv 
anil  liiii^r  ilnratiiiii  nt'  tin-  ili-ra-i.'  dn  imt  (•ninriilc  anv  iiinfr  than  ilu 
lircvitv  anil  tnildnr— .  Altlniiii:!]  ,-nrli  r.iinciilrnrc  nccnr-  trri|iicnilv 
in  the  iiulisidnal  (■■d-v,  tlir  M'Vcfily  and  ihr  duratinu  of  the  -vniptntii-- 
arc,  in  trcncral,  whnlly  iiidciirndmi  nl'  each  utlicr.  'i'hc  Kc-t  cvidciici' 
ot'  this  i>  atl'iii'<l(d  l>y  the  stiid\  nt'  thr  varictv  in  \iv  dr~rril)i'd  tir-t. 

The   Short,    Malignant   Variety   {Mn/i'/iKini    or    l-'ulmhintd 

Tji/ihoiil  J'l  rrr  :  Jh/jjii-jii/rilir  Wiriili/). — 'riii>  variety,  which,  fiirtiiiiatcly, 
is  rare,  riprcscnts,  a>  its  dc-iLniatinns  indicate,  a  furni  ot'  ty|ilii.id  lever 
dt'  iiiii.-t  -evere  <'iinrse.  Sitiie  nl'  the  ca>e~  lietrin  after  a  luiip'r  nr 
slini'ter  yieriiid  nf  iiiculiatioii,  which   is  nut    tree   t'l'uin   syni|)tiiiiis.       llic 

])atient^    iiiniplaiii    fur    days    in    ailvam I'   j:reat    inalai-e,    licadache, 

vcrliL''",  and  >lce])lessne-s.  and  iif'tcn  exhiliit  iian>ea  and  vmnitintr.  and 
nut  rarelv  diarrhea,  '{"lie  |iiil--c,  also,  at  thi-  tiine  may  he  ahiiDrniallv 
frci|Heiit.  and  the  teiii[ierature  tempurarily  elevated.  Jn  anotiier  j_'-riin|> 
of  ca-e~  the  di-easc  set-  ill  -iiddeiily.  wiihoiit  pnidnmial  iiianif'e-tatinn-, 
with  a  -^inLrlc  chill  nr  rc|ieateil  severe  cliilline--. 

Almost  aKvavs  the  stairc  ot' ascendini.^  lev-cr  is  eonsiderMhly  slmrtened, 
so  tliat  witiiin  from  twciity-foiir  to  foiiy-eiLrht  hours  the  level  of  con- 
stant f<n-er  is  resiclied.  At  times  thi-  occurs  at  once,  at  other  times 
with  one  or  two  sliL'lit  remis-ions.  The  teiii|)eratiir(  -level  then  reached 
is  not  rarc^lv  an  unusual  one,  so  that  as  early  as  lIu'  eveiiini:  of  the 
second  to  the  fonrlli  dav  of  the  disease  the  thcrmnmcter  may  retHster 
from  40.")°  to  41  < '.  ( I'ii.'.  ID-  'Ihe  temiieratiire  tlien  remains  at 
this  level,  L^enerallv  with  slight  tluetuatioiis.  |i)r  the  next  few  days,  or  it 
ri<es  -till  liiirliei,  |ireserviiiir  the  character  of  a  continued  or  remittent 
continued    fever  (FIl'.  -'i). 

The  pul-e,  even  in  rnhiist  men,  is  from  the  onti-et  excessively  fre- 
quent, at  first  still  full  and  tense.  Soon  it  liecoine-  softer  and  dicrotic. 
The  diil'erence-  Ketwcen  the  niorninvr  and  eveiiinjr  pul-e-trei|nency  are, 
like  tho<e  ill  the  temperattire,  reinarkalily  slight.  Shortly  licl'ore  or  at 
the  lieiLrht  of  the  fever,  at  times  even  diirinvr  the  a>eent.  the  patients 
heeome  stupid.  They  ;irc  delirious  at  nitrht  and  -ouictiinc  -  hy  day,  .'ind 
lie  in  ,'t  -tate  of  n^laxatioti,  in  pas-ive  dnr-al  dcciiliitn^.  with  the  mouth 
open,  exposini:   the  drv,  li-^sured  ton<rue  and    lips.      Snli-tiltus  teiidiniini, 


r.l/>7  r/7".V\   /.V  SYMITOMS     I.V/;   col  USE 


289 


fliMtitatii'ii,  and  ^n-iiii!iiiLr  "f  tli.  tcrtli,  in  ynini;.'  |n  f-niis  even  cinivii!- 
-iiiii-,  incrca-c  tlii'  irravitv  nf  the  clinical  picture.  Nut  fanly  ritriility 
dl'  the  hack  witli  (i[ii.~tli(iti)nii>  ;inil  (MIut  cciclmi-pinal  -vinptoin-  arc 
[irc-cnt   lic-iilc.-. 

'I'lio  >tatc  lit' the  -jilccii  is  varialilc.  (Icncrallyit  i- ili-tiiictly  ilctnon- 
straiilc  i|iiile  early,  even  at  tiic  time  ut"  ailiiii-^-iuii  ut  ilic  |iaticiit,  un  tlie 
x'ciiiiil  or  the  third  day  nl'  the  dl-ea-e,  and  iit'ti  ii  the  ur^ran  is  cnnverted 
into  a  Iar:.'e,  ^ul't,  and  -en-itive  tuinnr.  1,(--  cuininnnly  cidar;_'crncnt  of" 
the  s|ileeii  ucciir-  later,  or  i-  not  denioii-lralilc  thronirhunt  the  entire 
ciinrx'   i)t"  the  attack".      The  alulon  en   I'arly    hcconie.-   ^Meatly  distended, 


ii,.'.  ..]■  111.  |i 


« 


1^^*^?^^ 


"TT-- 


.+,-,-f      4.. 


m 


•  8 


Flo.  'lU.  'li-ini»--:iturr  rliiirt  fr..Mi  a  fulimimiit  nisr  ,if  ty|.h(iii|  ftvi  r  in  ii  woman,  tli 
yi'drs  (ltd.  tkTniiiiatir.K  fnially  uii  ttn'  liKlith  day.  lliis  wiu  thi'  thinl  ca^.e  in  a  h'niscc 
Thr  lUtark  lifgan  with  a  chill.  Inli.stina:  Usinns  wiTi'  niarkcil,  es)i<-rially  in  the  rc^-i.. 
cuinii  an. I  the  Inw.r  tliir.l  cf  th.^  iNiini  IVyer's  patrlics  were  in  a  statr  of  ini'iiiillary  s 
in  part  gruatly  Jisinli'L;raiiil  ainl  m  a  statu  ..f  rnni.'i'sti.in.    Nu  complicatinn  was  present 


iriy-tive 
mietnic. 
n  (if  ilie 
wi'ilinsf. 


and  ill  some  cases  ac(|nires  a  con^ider:ii)le  detrrrc  of  ten>ioii,  wliieh  Is  an 
ominous  sii^n.  'I"hc  -tools  are  at  times  diarrheal,  at  other  times  eon- 
stijiated  ;  tlie  urine  irciieniliy  contains  alliiimin  diiriiiLr  the  first  few  davs, 
at  the  stiine  time  luiiiir  scanty,  eoiicentrated,  anil  hiLdi-eolore<L  While 
ischuria  occurs  at  lir-t,  with  the  cornmencenient  of  deep  stupor,  the 
iM-inc  and   the  stools  an>  passed   involiintarilv   into   the  lied. 

The  termination  is  in  most  eases  fatal,  followinir  proirrcssive  lo.as  of 
strciijith,  anil  at  times  associated  with  extremolv  hi>rli  deirrees  of  tem- 
perature {liy])orpyretie  form).  Only  the  minority  of  patients  >iirvive. 
[ii  the  latter  event  the  severity  of  the  p'lieral  symptoms  snh-ides  toward 
the  end  of  the  second  week,  the  tem[ieratiire-ciirve  declines  to  ;i  lower 


fill 


i 


i 


I 


:  r^'  I 


2m 


TYi'iiofi)  i-i    t:i: 


i\(l,  s\  illi  -iiiiiillaiitoii-.  iinpniN  ciiu'iil  in  liic  |iiii-r  ;  anil  aih  r  a  liin;:tT 
(ir  -liiiilcr  |"rin(l  tin-  |iatirnl  liccduu-  al'clirili-.  (  ■unvali-ii-ncc  i-  alwavs 
iiiiu.-iially  -i\.ir  ami  pintrai'tLtl  ;  llii-  .ilicii  (n'ciir.-  in  con-ciiiiciicc  of 
ri(|-inlr-i(ii(c~    anil    i'ila|i-t-. 

The  -yni|iic.ni-  in  lljc  |iir~»  iicc  of  wliicli  death  take-  place  are  llmx" 
ot  iTL  >-t  |inirunnii  inlnxicaiinn.  Only  e.\ee|)ii,.Mallv  i|o  earlv  intereiir- 
I'l'ii'  iiil'  linal  lirini.rrliai:!-  arcelelale  llie  lata!  lerniinalion.  Tcwi- 
tnoruin  cxaininatiiin  ili-iln-e-.  in  areonhinre  ujili  tlic  -ii..rl  dnralioii 
(if  tlic  attack,  liiat  tlic  lc-i,.ti-  in  tlic  -mail  anil  ilic  lar^c  inte.-tine  are 
.-till  ill  a  ■-talc  uf  nicdull.iry  >\MllinL:,  and  oidy  licre  and  there  i>  tijere 
licu'innini:-  .-luMuhini:.  'riicir  extent  and  inti  n-it\  du  imt,  \>\  anv  inean>, 
al\\a\-  eiirre.-|ii)nil  with  the  severity  of  the  clinical  |iictnrc.  Althi.iich 
.-escfc  deirreo  of  i'lte.-linal  invulveiiicnt  are  nmre  trei|iieiit,  ca-i-  aKo 
occur    with    leiiiarkalily    -liLdit    ~|iecilic    inli-tinal    h -ions.       The    lafire, 

soil,  dillllielil   -jileeii    i-  oticn  the  -eat  of  recent  e\lrava-at  ion-  of  1.1 1. 

The  liver  and  the  kidmy-  are  in  a  ,-tate  of  marked  clondv  -wellinj^. 
l'oi-tinialel_\ ,  a-  ha-  liecn  --t.ated,  thi-  v.iriely  i-  t|niie  rare.  It  occnr,'^ 
princiiially  in  adidt-  n|i  to  the  tortieth  year,  while  children  and  old 
|per-ons  are  attacked  much  Ic—  freijiicnt  ly.  With  n  fcreiice  to  the 
diinitioii  of  the  |irocc--.  the  tiilininant  tiirtn,  \\hich  inav  terminate 
lat.ally  at  the  end  of  the  tir-t  week,  and  raivlv  per-i-t-  until  the  end 
of  till'  -econd,  i-  to  he  contra-led  with  the  maci'i.'  liirm-  of  |irotr;i''ed 
eoiii--e. 

Severe    and    Moderately   Severe   Cases    of   Protracted 

Course. — Detailed  reference  need  not  aiiaili  lie  made  here  to  the 
e<iiir-e  ol'  r-iieh  ea-c-,  a-  tlii-  ha.-  heeii  t'nlly  done  previoii,<lv  (( iencral 
Clinical  Picture).  .\t  this  place  wv  wish  merely  to  jioint  out  that  the 
<'oiiditioii-  and  the  form-  of  tlie  proloiiLred  attack  are  (wtreinelv  varialde. 
Tims,  the  jprolonu-.nion  may  he  due  to  the  fact  that  the  indixidiial  -ta^'t's 
of  the  disease  are  extended  heyond  the  ii>iial  |>eriod.  Tin-  applies  with 
esjM'eial  frei|Mency  to  the  l:i-lii;ium,  which  may  j>er-i-t  for  as  lonir  as 
four  weeks,  and  e\cii  much  lon;:er.  The  fever  lia>  then  le-s  ci.minoiilv 
or  only  in  the  first  stap'  the  character  of  a  continued  or  remittent  con- 
tinued type.  \'ery  early  or  even  from  the  outset,  the  tem|perature  is 
likely  to  exhihit  marked  lluctiialions,  and  mav  as-time  the  character 
of  an  iiiterniittenf  lyjie  or  even  liecome  wholly  irnirular.  Next  in 
freijuency  tli(>  stap'  of  delirvi-eeiice  is  prolcn;^ed.  '{'he  characteri>tie 
steep  curve-  arc  then  oh-cured  or  are  entirely  ai'-ent,  and  the  iuerea.-^o 
ill  tcinpcratiiic  lake-  place  L'radually.  with  a  more  or  less  [)rotracted, 
remittent,  or  wholly  irreirular  course,  in  which  there  are  not  infreipieiitlv 
caiisele.ss  remissioii?  aud   exaecrbatioufi.      After  defervoseenee  lia.s  fiiialiv 


taSLtTK 


u 


I  w./i//'/\v  /v  .sii//'7'/.i/s    i.v/(  CD!  i:<i: 


•_>!tl 


taken  placi',  ilic  ~la;r('  nt'  inm  uli-ccrni'  may  lie  iiiiu-iiallv  Innj.'.  Tin' 
|)aliiiit-  iriiuiiii  xsiak.  and  "pIiiii  ixliibit  niarkcil  in-taliilitv  cpf  |inr-i'  ami 
t«'tn|Kniinri',  su  iliat  iian-iiuiy  im  ica-r  inav  lake  [iknf  wiiluiiii  iili\ii,us 
cansc  or  npun  -li^rlil  iii-nViKaiinn.  (';l-i'^  air  -.A-n  I'ncincnt  in  ',\lii(li 
(■<in\  alisccnrc  i-  nnu-nally  |pripl(in;;ci|  in  (■(pn.-icjiicncc  ipf  rccrndcMcnccs 
anil  ri'!a|i-i'>  i  icp  iinic^rcMi  Ipppmi). 

riir  ini"liiatply  >c\  cic  an<l  npihl  tin'nis  niav,  not  los  tliaii  tlic  "-fviTO 
f'piiin,  !)(■   iniijnly  ippptraiii  il,  and   \  it    u'i^L'  nip  i  an-c  t'i>r  csiH'cial  anxiciv 

at   any  tiini-   in    ;lir  ippiir t'  llic  attack.      'I'lic   fever   i>  ilreii  f'nuii  the 

(int-it  iiiit  Very  liii;li,  and  is  (|nit(;  irfe^idar  nv  I'eniilteiit,  or  so  niaikediv 
inii  rniittent  tViPin  ilie  JHtiinnin'^  tliat  the  tein|iei'atnre-ehart  in  e<pnse- 
(|nencc  a('i|iiii-e-  an  a|>|ieaiani-e  which  seems  icniaikaMe  t(p  the  inex|)(ii- 
eiiccil  iph-<r\(r.  and  may  rtadily  ^ris'e  rise  to  l:il~e  cipneln-ippns.  'riuso 
cases  are  ai-ci  iVecjUently  [irpiluiii^cd  liv  rccriidc-ccncc-  and  relapses, 
which,  ill  c(Piir-e  and  intensity,  rc-cinliic  ihi'  prin.arv  attack  or  arc  even 
nioH!  -cvcrc.  While  ~e\(re  and  niipdi  lately  >es  ere  ca^e~  ^'ciierallv 
pursue  tiicir  c<piir7-e  in  IriPiii  |ppiir  to  ti\e  week-,  pnptraeteil  eases  iiiav 
keep  the  j)atient  in  hed  tor  Irpiiii  tiiree  t.  I'our  iiKPiiths,  and  even  Ioniser. 
Amoiiir  tlie-c  pr(ptra<'teil  cases,  tlipi-c  terininatini.'  l'atali\-  I'npin  maia— 
mils,  uiiich  liirtmialely  arc  of  extreme  rarity,  arc  deservin^r  of  special 
lueiition.  In  tin -i'  ca-c-  tiie  di-ca-e,  which  is  irciici-aliv  se\'en'  from  the 
outset,  is  then  ])nploiiL'cd  nininiy,  liiere  i- oficn  an  irreiriilar  tein|)cratiire- 
cnrve,  and  when  detcrve-ccncc  ha~  linally  taken  place,  the  patients  do 
Hot  convale-ce,  hut  their  condition  Kecipines  pro'/rc<-ivelv  W(prse.  The 
appetite  IS  not  restored,  hut,  on  the  contrary,  tiicv  is  di-taste  for  foinl, 
e^peiially  lor  meat,  ip(Puillon,  and  milk.  S;pme  patients  who  eat  even 
lairly  well  fail,  ncvcrthele--,  to  make  projrress.  The  howels  arc  consti- 
pated In  all  ihe-e  case-.  ;  the  ahdomen  is  hard  and  retracted.  The 
skin  a|>|)ears  dry  and  >caly,  and  the  hands  and  feet  are  cyanotic  and 
cold.  ICinaciation  jn-oirres-es  iuiiiitcrru])te(lly,  althou;:h  most  careful 
examination  fails  to  di-i|ipse  any  --ptcial  ori^mie  le-ion,  and  life  is  ter- 
minated with  the  mo-t  protoiind  marasmus.  I'lpst-mortem  examination 
in  such  eases  disilpp~es  what  elini(al  examination  had  alreadv  rendereil 
pHphaMc,  namely,  the  ahsenee  of  complications  or  anv  special  ortranic 
ehaiiire.  -Murclii-^ppii,  who  directed  especial  attention  to  this  form  of 
the  disease,  -tates  that  Hokitansky  attrihutcfl  it  to  shrinking'  (pf  the 
mesenteric  jrlands,  toc^cthtT  with  di>ai)pearance  of  the  intestinal  villi 
and  lympli-follich's. 

.\  cliar;i(lerisli<'  case  (pf  this  remarkable  variety,  to  which  even  experi- 
enceil  clinicians  make  no  reference,  came  under  mv  oliscrvation  in  con- 
sultation, occurriiiir  in  a  trirl  twcntv-one  years  old.  wlicj  lived  amid  the   iiKPSt 


ll 


m 


•J'.i-j  / )  rui'ih  1 1  \  it: 

t';i\nr:ililr  coiKliliiiii.-.  Alhr  :ni  :ill;iik  ..|'  l\  iilmi.l  I'.'Mr  ot'  ili\  fli  Wii  ks' 
iliiialiiiii.  wiili  irri^iilMr  innl  I'li  llic  wlmli'  li>»  IcMr.  llii  I'MIiciiI  !i|>|>r;iri'<i 
a  I II  111  1  III  ruler  II I  Hill  I'liiiN  all  -I  I  mi'.  I' lie  li'Mi|K'ral  iirt-  lii'iainc  ^iiliimrMial.  ami 
siMiii  riililicil  an  mni-iiallv  lnu  livd  ■!.i..i  nr  -11  ( '.  in  tlif  iiiuriiiiiL'.  I  in' 
piilx'  niiiaiiii  ll  liiiii.'-ualU  -tnall,  llinaiU.  ami  ii  lanli  il.  ami  liccaiiK'  |iriiL':'>>- 
.-ivi-lv  ~liiv,rr.  -I  llial  linalU  milv  -1^  nr  I"  In  al-  ■■uiiM  lir  cniiiilcil  in  lln- 
liiiniiu-.  Al  llii  >anic  liim-  iIm-  |ialiriil  u.i.-h'.l  in  a  iViu'lilt'iil  riiamicr.  ainl 
ii{ii>ii  llir  lliin  -km  >liTlrliiil  n\  1  i-  llii'  lioih-  lii'il  -nrm  ;.'railualK  a|.|'iairi| 
in  ihf  iiin-l  vaiKil  >iliialiiiii-  hmt  tin-  -ai  rum.  llir  Mruliia.  al  llu-  In  i  I. 
i-M'ii  ii\<r  I  III'  iliar  .-|iim'.  llir  ii|i|i.  i  i\i  ri  mil\  ol'  llir  lilnila.  ami  I  lie  ankli .-  ; 
ami,  al'liT  .-iilliriirj  Inr  a  Iuiil'  liim.  llir  paliiiit  liiialK  ilinl,  Inlal  iitrri.>i> 
lit'  I  111'  lit'l  ami  lirL'iniiiiiL'  iiccrii>is  nl  I  lir  riL'lil  inrina  lia\  iiiL'  aUn  ilivrlii|i(il 
ill  llic  la>l   I'cu  ila\-  III'  lili-.        \l  lln-  aiiln|i>y  iIhti'  Ha-  im  milcudrlln   allcra- 

lii I    ihr    iiilri'iial  \i-iiia,  uilli  llu-  I  \ri'|iliiin    111'  llu-  inli-.-liiii-.  w  liii-li  I'nii- 

laim-il  iiiiimriiiis  Mnnnlli.  |ii'_Mm  in  il  i-iralnri-  in  llu-  a.-i-i-iiiliiii.'  <  nlnn.  ami 
ill  llu-  ili'Uin  in  llu-  Nuiiiiu  nt'  llu-  ili-nri-ial  valvi-.  in  place  iit'  llie  I'cver'tt 
palelie>.  >ii  llial  i-vi-n  llu-  pallu'lnirie  aiialninv  uas  iiiialile  In  an.-^uer  llu- 
i|i;e>iiiiii   a.-    Ill   llie   (.'aiise   ol   ilialii. 

WcU-charactcrized    Cases    Pursuing  a   Moderate    and 

Mild  Course.  —  \\  iiili-  ililinili-  e\i,-riial  m-  iiiili\  iiliial  inniiil  imi-  'H' 
special  iireaiiie  ili-ea-e  iilli  11  ni\(-  ijuii-  iiiip|-i---  Id  i-;i-(-  111  llii-  el-iiiip, 
llie\  are  ill  ei-iieial  lii-liiej-iii-liei!  t'ri'lii  imt-  aiinllier  priiiii|>ally  iiy  tlieir 
(liiraliiiM.  Ill  a  iiiimlier  i.t'  llu-  i-a-e-  llie  iliiralinii  i-  -Imrn-r  lliaii  i- 
tile  averaire  ill  llie  Wi-jl-lliaikei!  -e\ere  ea-(-.  W  iiile  ntluT-  plir-lle  ei|lially 
a-  ImiLi  lull  a  iiiilii  ei.iir-e.  .\iiioMLr  tln'  ea-e-  nf  tin-  tir-t  kiiiil,  tlm-e 
an-  e-peeialU  iliaiaelt  li-lie  in  wliieli  llie  iiiili\  iiliial  >IaL:t's  <if'  tlic  (li>ca>e 
are  n-aiilar  ami  iiiaiiitaiii  tlu-ir  iiuriii.-ii  priipuriinii-,  altliuiifrli  tli«'y  are 
>liiirter,  Ml  llial  the  leiiipt  raliire-eliart,  e\ei  pi  as  tu  tlif  (liiratii m  nt'  llie 
\ariiiii-  -taL'e-,  eiilireU-  re-ciiilile-  that  ut'  the  typieal  variety  (  I-"iir.  II). 
(  )th('r  caM--  exliiliit  a  t:i\iiralile  (•(iiii>e  ill  that  eertaiii  iiidixitliial  stai.'-c-; 
of  the  (li-ea-e  are  eun-iileralilv  -horteiieil  or  remain  aliiio.st  imdevclopetl. 
Thu-.  the  initial  -taL'f  mav  he  almo.-^t  entirely  waiitiiiij-,  and  the  lieiirht 
111' the  f'i'ver  iiiav  lie  reaeheil  at  a  siliirle  hound  in  Iniiii  twelve  to  ciiihteeli 
iloiir- ;  or,  a-  oeeiil-  v.ilh  i-peeial  t'r(i|neiiey,  the  -taL'"'  "'  --tei'l)  eiir\  e- 
i-  eoii-iilerahlv  shortened  or  i-  not  at  all  marked.  In  the  latter  event 
tile  t'ehrile  -laire  i<  ot'teii  teniiiiialed  hv  a  eritii-al  ileeliiie.  C"oii,-ider- 
ahle  -hoileniiii:  of  the  aiiiphihiilie  -taue.  with  complete  development  of 
tile   initial    pirioij   and   that   ot'  eonvale-ceiice.  i<   le-.-   common. 

'i'he  ca-e-  of  modi-rate  and  mild  de'.'ree.  wliirli  are  iiiial)l)rcviate<l, 
liiit.  on  the  coiitrarv.  are  often  i^'icatly  proloiiired.  appear  to  ])urr-uc  a 
whollv  irrcL'nliir  cmir-e.  I'nder  the-e  eireiiin-tance<  the  febrile  stay:e 
maintain-  'ii  L'cneral  a  lower  temperatnre-levi-l.  I'lie  <Mir\-e  is  at  tlie 
same  time  likelv  to  exhihit  a  markedly  remittent  or  wholly  iiTcLrnlar 
eour-e.      'I"he   general    >ym|)toms  are   likely  to  he  exeeedinirly  mild,  and 


'A 


■di 


r  I/.7  i77'/\N  IS  s)i///"i/v    i\/i  I  III  i:.^i:. 


•_".»;'. 


ill"  iiii\iiU'  -y  tc-m  r-|i(i'l:illy  I-  Inn  littlr  invi>lvit|.  l-'mrn  ilic  diii;- 
ihi-tii'  point  oC  \\,\\,  tlii-i'  ("i-i'-,  a|i:irt  I'lmn  tin-  I'lcl  tli:ii  lli>  t'l'Vcr- 
rurvc   trii|iii  iiily  L'ivi-  ii'i  :ii<l,  ni.iy  I'lirthcr   I.      i  -ninir  ci'  inii-.di  imMc 

ilitliriiliv  Imi'.iii-i'  oI'  till'  ;ili-iMn 1' -|il(iiii'  ciihiiiijoiiJtMit  nr  it-   iiiiii-ii.illv 

!:itr  ili'\i'lo|iiiiiiil.  K'  I  .iii~r  III'  ihr  -I'anliii  nl'  llic  n)!H'<>ln',  nr  iiialiililv  lo 
ili'iiioti-lrali-  lliitri,  lliriiiiLfliiiiil  llir  i  lit  ire  I'liiif-c  nl  tin-  iJi-iM-,  ,  a  in!  m  r  i  - 
«iii|ially  al-ii  liccaii-c  nt'  llir  iii-i'_'iiiricaiil  rhafa'trr  nl'  tlic  iti*i'~liiial 
-vtii|)li)iii-.  '^iii  li  ca-i-  arc  |p|iilialil\  tlif  -aiiif  a-  llin-c  tlial  earlier 
[iliy-ieiaii-  cle-i^'iiale<l  a-  sjra-lrie  lever  nr  a-  iiminii-  te\  er,  ami  -<|>arateil 
elii)loi:ieallv  iViiiri  t\  plmiil  tiMf.  It  i-  (ililv  a  .-te|)  rrmii  tlie-e  Miuiieiate 
aliil  iiiilil  ea-e-  In  lliu-e  |iiii-iiiiiL:  all  cspeeiallv  slmrt  ami  rre<|iieiitlv 
aKo  an  e-[ie(iail\'  liiiM  emir-e.  Tlie^e  are  real]\'  -eparaltle  (ililv  ~nper- 
tteially,  I'lpp  tliey  are  aetiialiy  e>pimeete<|  l(v  all  |(i).-il)l"  (rati^itimial 
t'onu-i. 

Atypical  Cases  of  very  Short  and  Mild  Course  (Ti/plius 

Alinrtiriis,  '/'iijiliii.'<  f,i-ris.sliinis,  Ti/jiliniilrttr  (  Hiininrili /).  —  In  earlier  times 
tlicso  ea-if'S  were,  ^till  le^s  tliail  tlie  preeeiliiie-  fiiriii>,  eipii-i(lere<l  a.-  e\am- 
[)les  of  typliiiid  I'ever  Altlidiiirli  Leliert  '  <H'eiipie<l  liiiiiself  with  their 
study  and  emitriliiitnl  sDiiiethin;;  to  the  ktiowledirt'  '<i  tiiein,  it  reiiiaiiie<i 
f(»r  (Iriossiiiirer  -  tu  dennni^trate  heyntid  do.iht  tiieir  nature  and  their 
relatiiui  to  ty|)hi>i(!  lever.  lie  was  tiillowed  by  .liire^ensen,'  Bauniier,' 
and  other-,  who  hel|)ed  to  jrive  «-learness  and  tiinv  to  the  new  doetrine. 
Ail  the  ca-es  included  in  this  firoiip  are  eharaeterizwl  hy  the  espin'iai 
sliortness  ot"  the  eotiive,  and  fre(pientiy  also  l)V  the  marke<l  mildness. 
.Mildness  is.  however,  a>  has  heeu  mentioned,  hv  no  means  always  a 
oharaeteri-tic  featiire.  On  the  contrary,  the  well-developwl  ca.-<'s  mav 
1)0  elassitied,  aeeordinj;  to  the  -U}x^e-tion  of  Liehermeister,  into  mildv-st 
ease;  (Ty|)hus  levissimn>l,  ineludini:  all  ea-es  ehararteri/tsl  l>y  mild- 
ness and  hy  hrevity,  and  into  a  se<'ond  class  (Ty])liiis  al)ortivus),  which 
includes  those  eases  in  which,  althoiifih  ihe  course  is  short,  the  character 
of  the  disease  may  at  times  he  <|uitc  severe  an<l  even  alarminsj. 

If  the  manner  in  which  tiie  mild  and  the  abortive  cases  of  tvphoid 
fever  make  their  appearance  he  more  minutely  observed,  it  will  bo 
touiid  that  they  exhibit  in  varyintr  deirree  the  evidences  of  imperfect 
<levelo|)mcnt  of  the  disea-e.  W'e  have  observe  I  that  in  the  mild  cases 
one  or  another  staL'c  of  the  dis(>ase  is  often  aiibrcviatetl,  but  in  the 
ca-e-  under  consideration    this   -horteninjr  o(\en   attains  a  ino-t   extreme 


'   I'm;!.    Virrlri;..    1  S.IT.   Hil     Ivi. 

'Schmidt.   htn'in_   f>iss..  Ziiricli.  1Rr,i>;   and  t>iffJifi„n!if:ra>\khfitrn.  \9.r,i. 

'  \':,ll,-7tiniiii'x  Sniiinilinui  ijni.    \',,rtr  .    ]^~'.].    No.  ill. 

«  n>,hnii  MnL  J.,ur..  N.iv..   ISSO:   iind  Prutxrh.  Arrh.  f.  /Jit,.  MH..  Bd.  iii. 


Wi^- 


•  l.'-irc.  All  tlic  ^ta-c-  iii:iy  lu'  cMi-Mcnihly  .-licrtciicl  in  tlicir  cuiirso 
ill-  may  I,,-  -,,  al>i  idncd  a-  to  Im'  umvco^rni/ahlc.  .\-  in  llic  ca-c-  <.!' 
in.«l,TaIr  severity.  >,.  aUo  in  tlir  Miil,|,-t.  tiii-  al.l.icviati.m  inav  alUrt 
th,'  initial  an.l  tli^  t.niiinal  >Ia.rc^  (-.pccially.  -oMiriiriK-  in  ih,.  ti.nn 
nl'  an  ahnipt  imm.  m-  a  .Titi.'al  .Icclinr.  .ir  l\urr  may  !,.•  a  .|nil,.  -Tadnaj 
'■'""""■'"•'""•'I'  '"•  >ni>-i,irn.T  nf  ill,.  t;.v,.r.  It  >l:,,ul.l  l.c  |H,intc,l  <.nt 
that  .•..n-i(lci-al)lc  -hortrnin-  of  the  initial  -laL'c  and  critical  .Icclinc  of 
tl].'  fcxvr  (iccnr  nioiv  lVc,|ncntly  ir  ca^-  ,,f  al.nnivc  typhoid  than  in 
tho-c.d'thc  mildc-i  variety.  'I"h,.  i;i>ti-imu  ..f  the  di>..a,-..,  which  like- 
wise i-  fre,|uently  more  ,,r  I,--  -ivatly  -Ih.rt.'iicd.  may  i^xiiilrt  all 
|"i--il>le  varieties  nf  temperatiire-eiirvc.  from  that  of  the  ivirnlar  reiirt- 
lent  continued  c,uir~e.  whi.h  i~  de,.idedly  the  leaM  cmimon,  to  that  of 
the  |.nre  inter  aittent  or  wholly  irre-nlar  conr-e.  with  low  or  m.Klerate 
telnperalnre. 

The  pnl-,.  i-  likely  to  he  particularly  accelerated  and  to  l,e  mistalde 
only  ill  irritahle  women  and  ehiklrcn,  while  in  I,  -  -.ei|.-itive.  nioiv 
rolin-t  individuals  it  exhil.its  scaiwly  any  acceleration  tlnvui-lmut  the 
entire  course  nf  the  di-eav..  Kveii  in  the  aln.rtive  ,aMs  with  |,it_di 
luiy -r  tl.r  ,ii.,:i.,.  t<'m|ii'raliirc   at    the    outset,  the 

^liiiht  d(;:ree  of  ,  crease  in 
the  frei|Uency  of  the  pulsi'  is 
at  times  cs|ieeially  slrikiiiir 
(  i'"i,Lr.    L'lt). 

IJetore  |)assinir  to  a  coii- 
-ideration  of  the  reinaininir 
-symptoms  of  the  ahliivviateil 
;iiid  till'  milde-t  easf -.  a  few 
histories  with  temperatiire- 
tracintrs  may  he  luiitlv  iriveii 
to  ilhi-trate  the  \arioiis  ii.niis 
ot'  course. 

'I  he  f.iilnw  ]uij  ciisc  ,|i;,v  1„, 
coii>i(|eri'il  as  (iiie  of  ahortive 
tvplioid  iVvcr:  A  ceinpnsitor, 
ninel(cn  years  olij.  after  several 
da\  -  (if  liead;i'-lie.  anorexia,  and 
|'l'o-li-;iti()||.  \\;is  sli.lilciih  sei/ed 
.    .  wiih  a  chill.      (lii   the  ,|:iv  of  ad- 

riiission  <s,w.,„|,l  ,]:,y  of  the  .jisease  .  .MilarL'cMi,.nl  of  the  s,,lcen  was  ,riMiiicilv 
demonstrahle  i'.etween  the  toiirlh  ami  the  lif;h  dav  a  M.iall  nuiiiher  of 
niseohe  ni.iile  their  appearance  upon  lliecli.-t.  1  In-  arM|n.,,cii.  and  the  hack, 
and  wore  Injlowed  hy  others  up  to  the  nimli  ,iav.  On  the  .,  cond  d:,v  of  the 
di.seasetheeveniiiL'  temperature  was   1(1.1.'    ( '.,  and  from  tin- time  on  miiil  the 


2345     6789    10   11   is] 

-  41  --  '-  •  ^   T-  i-  -^  /  -L  ',   ;  .:t 

^:-J\  •  J  •  J^  ■  -  *   •   • 

M^fm^ 

:=■:  :   :   :   :.^:   ;   :   -^ 
38-- -  =  '.,'..:  :  .:   :   :   : 

^-:-mHE 

35    -  •  ^    .'--i-.  -'-.  -I-  1.  I    '    ;    , : 

r.iA7.r/vo.v\  /.v  sy.ui'To.us  A.\n  cnrr.si:. 


sixth  ilay.  on  wliich  the  cvciiiii:.'  ttinjirniturc  nachcd  40.tr  ( '..  th..ri'  was 
(•oii]|ianiiiv(ly  liiirli  ccnitimuMl  llvrr.  «hich  tlicu  ileclincil  ra|ii(llv  in  tv.o 
stUiTrs,  anil  loiiipU'lc  (IrKTVcscfiicc  ()(ciirrc(l  afUT  tlie  eif:hlh  or  the  niiitli 
ihiy  .  Iml'.  I'li  .  TIk'  |)Ii1>c  (liiiiiii:  the  iMirile  period  raiijred  hetweeii  100 
and  IL'O,  and  was  fid!  and  of  hi_di  ten>j  -i.  Convalesceiiee  was  uiieniii]iii- 
eated.  and  tin-  patient  was  disinis.-ed  after  thr.-e  and  nnc-half  weel^s  nadv  to 
rettirn  to  w<)ri<. 

The  leniperaliire-elian  sh  wn  in  Fi;:.  L'7  is  from  a  ea.-ewiih  nine  davs  of 
fever,  on  oidy  two  or  three  of  whiiii  the  ti'ni|ieratnre  was  hii'h.  hnt  which, 
nevertheless  exiiiliited  a  severe,  even  ahirinini.'.  aspect,  '{"he  patient  was  an 
ohese  a.ssessnr,  tiiirty-si.x  years  old.  wlio  had  drnnk  a  piod  deal  of  In't-r  and 
hail  eaten  ireiierousiy,  thonL:h  eiiLML'-ed  in  lint  sli^rht  jiliysical  a<'tivitv.  llu  was 
seizeil  with  a  chill  on  .;  retnrn  Jonrncy  from  Italy.  As  earlv  as  theVeeond  dav 
of  the  disease  a  larire.  palpahle.  sensitive,  spieiiii-  tumor  was  presi'iit  ;  on  the 
third  day.  an  aliiindauce  of  rose(d:e  on   the  trunk,  the   up|ier  arni.<.  and   the 

I'av  ..r  til.   .lisi-iis.' 


thiL-hs.  From  this  .lay  on  there  were  stnpor  and.  towanl  eveinuL'-  and  in  the 
nitrht,  active  .leliriuni  uilh  attempts  at  Hi::lil.  From  the  fourth  to  the  tenth 
day  tliere  was  mod.'rate  aihiiminnria.  at  first  even  with  >lii;ht  admixture  of 
hlood  and  of  hyaline  and  epithelial  casts,  and  a  small  nund)er  of  hlood- 
ea.sts.  As  will  lie  seen  from  the  tem'ieral  ure..'hart.  the  fever  siiliside.l  ^'ra.l- 
ually.  Complete  defervescence  was  attained  lietween  the  niL'lit  of  the  eri'lith 
an.l  the  morriin:r  <if  the  ninth  dav  liy  a  sort  of  critical  decliiu-.  which' was 
attended  with  profu-;e  sweatin-  The  >tale  of  the  pul>e  W!^^  from  the  out- 
set cpiite  favoraldc.  iMinir  intermittent  now  and  a-ain  durin-  the  tirst  few 
ilays.  hut  never  especially  ,-niall  .ir  fre.picnt.  Convalescence  w.'is  nnusn- 
ally  protracted.  ~o  that  the  patient,  in  spite  -if  the  .-hort  duration  of  the 
a.'tnal  fehrile  sla-c.  u.m.>  not  .ahl,.  to  -,  i  out  of  h.-d  until  after  four  and 
one-half  weeks,  and   then   with   a   lo>s  ot'  uei-lit    of  I'.i  pouii.is. 

J?y  the  side  of  thi>  cvi~,.  may  he  placed  that  trom  which  the  Iracinir 
shown  in  Fi-  L's  was  olitaiucd.  This  occurre<l  in  an  enihroidercr.  twenl\"- 
one  years  old,  who  was  admitted  on  the  fourth  dav  of  the  disease,  and  entered 


liii    I 


# 


0^ 


■t*i. 


L'lHi 


Tvriinii)  1  i:vi:i!. 


iil"in  ilt<'iTV.'S(vii<T  1)11  llic  lliiric.'iilli  (l;iy.  Tlic  clinical  pictiiro  was  s.vitc 
milil  ilic  clcvciilii  ilay  of  the  li'vcr,  wiili  niarkc.l  apalliv.  .-oiiiii,il,.iii'c,  an. I 
.-liirlil  (Icliriiiiu.  Tiic  ciiur.scdf  the  lctn|K'raliirc  cxiilliiifil  the  cliaraciir  ..fa 
ralliiT  .ilk-liiKilc,  niiiitlcMl,  coiainiic.l  fcvcr  of  ino.lciatc  dir'rci-.  Systtiualic 
trcatiiicnl  willi  haili,-  was  rcniirc.l.  llic  ctl'ci't  ..f  whi.li  ua.-  I.ul  sli-lit  an. I  of 
sii.rrt  .liirali.iii.  On  a.hnissi..n  a  lar-c  |.al|iali|.-  .-plciii.-  i  un, or  was  |, resent, 
and— wliat  ina.le  llii-  ca.-e  a|.|uar  esjiecialiy  remark:,  hi. •— then-  «;:s  an 
iinnsually  pn.fnse  eru|,ii..n  ..f  rose., la.  whi.'li  c.niiniie.l  \><  inulliply  iiniil 
the  .■veriini:  .it  the  llflh  ,lay.  .-.,  that  a.-  many  a,-  7:>ii  .'..nhl  he  .■..mileii  iip.ni 
the  hark  an. 1  the  extremities.  The  ]uil.sc'reinaiiie.|  nl:itivelv  i:oo,l.  even 
at  the  h.'i-ht  <<['  the  fever.  heitiLT  always  i'lill.  rcL'tilar.  aii.l  tense,  hut  hein}: 
in..r.'  than  1  L'O  ,,ii|y  .,n  die  first  eveiiini:,  an. I  thereafler  ran-iriL'  ah..iil  1(10 
anil  hel.iw. 

'Ihe   f..ll.iwiie_'  ease  exiiihiis  a  certain   contrast  to  the  L' severe  .'ases   jnst 
iiiciiliuiifd  ;    it   likeui.-e  was  attetided  with   fever  of  nioderale  deirri'i',  hut    it 


l>.iv  ..f  tl 


Fir;.  28. 

did  not  for  an  hour  exhihit  any  sovere  or  alariiiitii:  svni|)toiiis  even  at  the 
hei^lit  of  the  disea.-e.  It  oi'cnrre.l  in  tin  extrenieh  rohiist  lio.stlcr.  Iweiitv 
years  ..hi.  The  tever  histe.l  a]loL.'ether  for  nitie  .lays.  t!ic  markedly  remit- 
tent an.l  interiiiitteiit  curve  risini'  <;enerally  in  the  eveiiitijr  to  from  oit^  to 
;>!•.  I  '  ('..  and  finally  exhihitiiiL'-  a  jiiiailiar  and  rare  varietv  of  critical  decline 
in  two  staL'e.u.  lietween  the  ninth  ati.l  the  lenlh  day  tlie  teni|ieratMre  fell 
from  .'J!)°  to  .')7''  ('..  then  fhictiiate.l  ti.r  two  days  hetweeii  .'IT"  and  oT.ti-  ( '.,  to 
decline  airain  sn.l.ienly  helow  normal  hetweeii  the  eleventh  and  twelfth  davs. 
and  [lersistinir  at  this  low  level  .hiring'  the  first  part  ..f  convales.'cnce  (  Fiir. 
2".l  I.  As  the  temperatiire-eharl  shows,  the  |Hilse  in  this  c'l^e  wasfV.mi  the 
oiit.sel  iintis. tally  slow.  alth..U'_di  always  full  an.l  tense  ;  at  ii..  tiin.'  was  the 
setisoriiim  ofth.  patient  in  any  deiTee  iill'ected.  and  he  e.impljiine.l  of  hiiiiLrer 
even  hefiire  the  suhsi.len.'c  of  the  fever  :  after  a  lirief,  nninterruptcl  con- 
valescence he  was  restore.!  to  his  full  eapa.ily  for  u..rk  with  remarkahlu 
rapi.lity. 

The  followin','   ca.se   pursued.  ..n  the  whole,  a  severe  course,  with  various 


IWUrATI'JXS   l.\  SYMI'IOMS   AM)   <nC/!Si:. 


I'^IV  nf  (Ih-  .1 


l'!»7 


.siilijectivc  complaints  ami  for  ilays  a  sniali,  although  not  inidulv  f'rt'iiuciit, 
piiUo.     This  is  an  exanipii'  of  almost  complete  inlerniittencc  of  tiic  lonipera- 


Piiy  of  111,,  .lisi'iis 


tiirc-curvc  from  ihe  tirst  day  of  oliscrvatioii.  ami  prolialilv  from  tlic  licLnniiinp: 
of  the  fever  (  Fij:.  oO).  The  patient  was  a  irirl,  fifteen  years  old,  in  whom 
enlar>;enient  of  the  spleen  was  demonstrahle  on  the  fifth  day.  with  moderate 


\im 


li'J.S 


rvninii,  I  i:vi:i:. 


i 


(llM,MiIi(Mi  ot    the  Mli.lon,..M  ;in.|    -ll^r),,  ,,.,,. |,.l•m■^.■<  i,>  the  ilcocwil  n-ioii,  iukI 
''■""'    ''"■  -^•■V'l.ili    I"  ilu-    lliirt.M.iill,  .liiv   tw„  „r    tlirc-  tliin.   iica->oiii>.like 

Mnnis    «,T.-     pa.-.,-,|     ,h,ily.        Thr    ,n r,'    nf    iho     pUlilMll      l,M.i    ,li,.,|     ,-l,„rllv 

ic-lufc.  Ir.iii,  :ii,    :,ila(k  of  the  ,univ.-l    i;..-i.  of  lv|.l,oi,l  tl-\.-i-,  uiii,    i,it,.MiiiMl 
licrnori-liML'c-. 

'I  li''  lollouin-  r;,,-,.  will  „.,-v,'  :i>  an  ,x;nH|.lo  ,,f  iriir  lv|,|ioiJ  f.-vfr  of  tlio 
iiiiM.st  Iy|,c.  Il„.  |,ali.ni  ua.~  a  mail.  Ion  n -.on,,  vcaix,!,!.  wliolia.l  lu'cii 
m'<l<i-  inalriirnl  in  ih..  lio>|,i,al  tor  monili.  fo,-  ,:,!„.,  ,|,,ixili.<,  hut  ollicrwi^e 
1k'  ua.  rol.uM  an.l  well  iiouri.-lu.l.  Thr  o,,.-.  t  of  ih,.  .lUaM.,  uhicl,  was  not 
prorrdrd  hs  J .ro. horn.  >.  u as  altrii.lr.l  wiih  vhilliiios.  As  carlv  as  the  tim 
(lay  cnhirL'.'inrnl  ,,f  lhr>pl,.,n  «as  ,i,  inoiistrahh.  hv  ponn^.-ion'.  and  on  tlu- 
t.iml  (lay  as  well  hv  palpaiion.  A  -niall  iMiiiihcr  .if  w,ll-,l,.v.>l..pr.l  niMM.Jii. 
appcart-a  rclativ.ly  lai.-  h.iu.,,,  ll..^  -ixih  an.l  ihr  n.nlh  ,lav.  Thi-ou-l,. 
out,  tlio  cnm-ecoiiix'  ..f  ilu.h-.a.M.  ihoiv  was  i...  .Iiarrhca,  hii't,  ..n  tin.  ,■.„,- 
trary,  .■oiislipalion.      (  .,nvalc.-c,n,v  pro-nsscl   rapi.liv,  and  at   its  do-t-  the 


l'M>     I   r   II. r    ,h~' 


pntioiit  wois-hpii  five  and  a  half  poun.ls  more  than  a  week  hcf.irc  the  hcL'iii- 
imii:  ot'tiic  discas.'  .  V\j.  :U  .  'Ph,.  Icnipcraliirc-cliart  of  th,.  .'asc  is,  as  is  so 
frci|ii('nt  ill  the  mild, si  casi's  of  tvpli.ii.l  fovcr.  \\h..il\  iini'hara.'I.ristic.  The 
tenipcratiirc.  alt.'rnalclv  rciiiincnt  and  inurniilicnl, 'hut  .m.'c  r.ai'hci  .•J!t°('. 

M  itli  n-ar.l  t.i  the  .(Hiiv,.  ,,f  th,.  ino,,iii])l(li'ly  (Icvci.ipcd,  al.hrcviatcd 
(•as.-  ill  ijciLpal.  it  has  l„,.n  point. .,|  ,,iit— an.l  ..!'  llii.-  iIip  .asi-  last 
related  .ath.rds  a  li'.i.iil  illu-lraiioii — that  iiiaiiy.  in  .•iddilion  to  the  i.revilv, 
ai-e  characterized  li.-id.-  iiy  imii-iial  inildiie-s  ,,f  the  sviiiptom,~.  .si.  that 
th.y-  w.'ll  d,-. TV.'  the.pialiticati..ii  ••  iiiil.lc-t."  ■jdic-e  .'a-.'s  set  in  either 
im.  \pecl.dly  with  a  .hill  ..r  .a  ii'diii-  .,f'  .hillin.--.  or  aft, r  -li-hi  pr,,- 
dnmies,  and  then  the  tn.ixiiniiiii  tiinp,  ratniv  i-  r.  .1,  h.  d  .itli.r  u:radi;  dlv 
or  more  rapidly.  ...•.■a-i,,nally  lieliuv  the  .11. 1  ..f  i  u  .iity-liiur  h.uiiv.  In 
all.  the   u'ciicral    c.iii.liti..ii    i-   l.iit   sli;:htly  di.-mrlied.      The  patients   are 


■  i 


y.inr.iTioss  ix  symi'toms  ami  coiksi:. 


•2<.)'.) 


:it  iiiiot    .-oiiicw  liat   aiKitirctic,  rc-lif-s  ami   -Iccpl  -s  at    iiiuilit,  l)iit   aliiiii>l 

wlidlly  witliiiiit   ililirimii.      Tlic   piil-c  i-iinaiii-  <_'■ I   ilinnii^'liuin,  and  i- 

oi'teri  nniarkaldy  -low.  ( 'nni|iliiati(iiis  and  unusual  liHalizatioii  of  tliu 
typlicid  proco-  arc  cxtivinclv  raiv.  After  ilic  fcvc-  ha,-  la.-trd  Ihun  m\ 
to  ten  day-,  (lie  |>atitiits  rt'cuvir  rajiidly  and  rciui|)lit(l\ . 

A  niliid)er  of  ca.-LS  tli.it  should  likewise  \,v  inriudid  in  the  cattjrorv 
of  tile  niildot  form  of  typhoid  f.vcr  (■\hil)it  <liiriiij^  tlio  fu>t  few  davs 
.xovi'i-c  liiit  traii-iiory  ^rcniral  luanitistation.-,  with  -onu'what  higher 
foviT,  hilt  till!  cniiix;  siil)>c((ii('ntl\' a.s,~iiiiic.-  a  mild  cliaracttr,  toiniinatiiif; 
in  niU'oniplicatc<l  (•onvalcscfiur.  W'v  may  also,  with  a  cciLiiu  diLrrw 
of  propriety,  iinludc  in  tiie  rla-s  of  mihl  eases  tlK^se  which  exiiihit 
rel  itively  hii.r|i  remitlent  fever,  which  persists  for  days,  lint  which  i~  not 
aeeompanitd  i)y  corrcspondiiiir  acceleration  of  the  piiNe-frcHinenev  or  hv 
especial  distiirliance  in  the  general  condition,  and  in  w  liicli  eoiivali'scenei! 
heirins  in  the  course  of  six  or  ciudit  days,  liie  lever  siii>sidiuir  1.  crisis 
or  rapid  lysis.  'I'hey  occupy  a  position  midway  lietweeii  the  "t\  pints 
levis"  and  the  •■typhus  ahortivns  "  of  Licliermeister,  constitutiiiL'  :i 
transition  lietween  these  j.n<>iips,  and  in  their  ty|iieal  form  tliev  ilins- 
frate  tiie  saying  "  I'arturiunt  moiites,  macetnr  ridicnlus  mus."  Siu  h 
cases  irciicrally  he^'in  with  aiirujit  elevation  of  temperature  foliowinir  a 
chill,  and  are  marked  at  times  hy  (piite  severe  symptoms  ol'  treneral 
intoxieatioti  at  the  height  of  the  fever,  wlucli  at  night  mav  attain  a 
level  of  llt^  ('.  or  more  ;  t'icy  also  occasionally  show  es])e.Mal  involve- 
ment of  the  internal  vi-cei-.i,  -uch  as  particularly  severe  ditluse  hron- 
eliitis  and  alliuminnria  ami  ne]ihiitis  of  earlv  onset.  The-c  cases 
almost  make  the  impression  that  all  the  severe  svmiitoms  of  tv|)hoid 
fever  were  Keing  <'rowded  into  a  short  time;  and  thcv  not  iiii-elv  give 
rise  to  anxiety,  which,  Iiowever,  is  soon  dissipate<l  hv  a  critical  or  at 
least  rapid  subsidemr  of  the  temin'raturo,  often  accompanied  hv  sweats. 
Kvidence  of  the  fact  that  severe  di^tnrl)aIlces  have  taken  place  in  the 
hody  even  during  the  short  duration  of  the  disease  is  allorded  hy  ti.e 
tact  that  convalescence  is  often  disprojiortionately  protracted,  strcni;th 
is  hut  slowly  regain(>d,  and  the  loss  of  weight  is  at  times  verv  con- 
siderahle  (see  the  case  illustrate(l  hv   I'"iir.  -")• 

The  course  of  these  true  ahoi-tive  cases  -s  gcnerallv  as  loni:  as  that 
of  the  mild  and  very  mild  cases.  Kvcn  more  markedly  than  in  the 
latter,  one  may  note  that  tin  incompleteness  in  development  is  at  the 
cxpen-e  of  tli<'  ii]iti:d  stage  and  the  ])er'«l  of  deferves<'ence,  so  that  the 
duration  of  the  fa-tigium  with  relatively  high  lever  is  ot'ten  rather  pro- 
tracted. With  regard  to  the  course  of  the  fever  during  the  latter 
period,  the  remittent  eintinuiil  type  predominates,  hut  complete   iiiter- 


mi 


MO 


I  )  l'U<ill'   I  I  1  /,/;. 


mittfiifc  mikI  ali-nhitc   iirc;:iil:irii\   in   tin.  irinpcnitnn-curvr   iiimv  csi-t 

tiiucllii  r  \\  iili  iil.ii'rnin;^   ;:('iiiral    luaiiil'c^talinii-.. 

^\  I'il'-    -I-  li'i-    l"'ii    (iiiiiha-i/id,    til.'    -iiinal    iiiaiiiti-tal  iun^    in    ||„. 

"'il'l'-'    '••'-'-  "•'   i\|'li"iil    Irwr,    a:-    \\,\\    a-    (Iimm     re  liralilr    in    -iri-lc 

'"-'"'--   :'■'      lil^'lv    1(1     Ipc    cXInihrl^     lllilil,     ill     alinl'livc     t\|il|,,i<|     t'rvcr,    ill 

-|.iic  ..r  llir  -li..ri  ,|iiraii,,ii,  .criaiii  i.r-aii-  an-  at  lime-  -i  ri.,ii-K  alir.'icil 
— a  tmilici-  cMilcii,,. ,,!'  tjj,.  M\(rii\  di'  ijir  iiilicii,,ii  umlrr  ccriaiii  liiviim- 
>taili'(-.  Tliii-  ih,.  ra-r  illiiMral,.!  I.v  Fi-  _'7  .-licwcl  ihal  alhiiiiiiiiiiria 
may  l.c  piv-ciii  a-  early  a>  tlir  li.iirtli  day  of  tlic  diMa-c,  alllioii-h  in 
.-CM  IV  caM'.-  (if  til,,  (inliiiary  t\]if   ii    i-   ii,,i    |i|,,.|y  to  a]i|Mar  liclim'  tile 


1 

'> 

r  t 

l;-c 

1-.. 

3 

4 

5 

e 

7 

8 

9 

10 

11 

12 

13 

U 

16 

16 

T. 
41 

-♦- 

— 

^ 

:- 

i 

-■■- 

"- 

\ 

— 

40 

-t   - 

r 
if 

• 

''■- 

39 

J 

h 

' 

38 

/ 

/ 

^  A 

' 

^ 

J 

■4 

^ 

37 

"i 

t 

f- 

1. 

1*7 

i 

\f\ 

/I 

/^ 

1    1 

3B 

"i 

i 

■■-r 

,1 

t 

\ 

i 

/ 

35 

1 

1 

•  - 

V 

. 

il 

= 

I 


iiikMIc  (,f  tlir  sccoii,!  urck.      Siill  III,,!-,.  in-ti-iK-tivc  i-  a  cax'  of  ahnftivo 

or    mild   typhoid    fivn-  whi.li   v\a-    iiiidrr   my  uliMi'vali tlir  ,,ii>,.t    of 

uhid    «•■-;  atlnidrd  willi  iir|phiiti-,  and  which  piir-iicd    it-   couf-c   amid 

the   rli.iiral    iiiaiiil'i-lat inn-   ..f  the   latt.r  litioii,  and  wliirh  thcrcfirc 

may    lir  ap|)ru|,riat,ly    callrd   an    cvamplr   of  iir|iliroty|ilioid. 

A  salfsuoiiiaii.  lunily  yrars  old,  was  ailiiiittcd  tiir  liriiiorrliiii:ic'  iicpliritis 
nftfi-  >hc  had  liivn  ill  f,,r  i«,,  ,|ay>.  TJ!..  ai'ioiiiit  of  ni-jii,-  ua;-  ciiiLsidinil,! v 
diiimii-jii-d.  and  ilic  .<ciTcli(iii  ua>  dark  and  l.|oi„U  ami  I'oniaiiicd  an  iiluiii- 
daiKv  nf  all.iiMiiii.  iar-(.  iniiiilici>  of  cpii  iuiial  ci'ls,  and  hvaliiie  and  l.lood- 
(•a>l.-.      Tlir  UMiipcraturo  J-"i^'.  WI  :  which  was   '■>-     {  ,  m\  the  cvcninir  of 


-S^iil::: 


.j:,  ■'■,,y:*^-  ^i4^:$i,fjcw;.,v^-;^^-'?::^-^' ?/;;:'  vf.:-v.^.^.-i^i:^:i'.-.>^i^  v.; "i.^;^ 


r.i/;/ 1 /vo.v.v  /.v  MM'/'Voi/s-  .i.v/;  (nrnsi:. 


;j()l 


till'  thiril  (l;iy  dl'  llif  ili.-cast',  ro.-i'  mi  the  liillciu  in;.'  tlircc  il'\>  to  Ih'Ihih'H 
il'*.  t  :iiiil  ^II'.tJ'M'.  In  :i4'litii)ii  to  tlii>  ilrLTfi' nt' flcv;ili(iii  (.r  tfMi|H'i-:itiirf, 
ulilrh  «;i.-  cniL-iicltTul)!!'  lor  :i  cast' of  iiiiil.'  Mcjilirit i.-.  llic  iial|ialilr  ciilMrLH'- 
iiirn'  of  ilic  ^|lll■(■ll  [hat  was  |in>cnt  on  ailiiii>.-i(iii  was  .-Irikini;.  (  )ri  llic 
liinr  a_v  ot'  tlic  iliM'asc  ili.-lim-l  rovohr  inailc-  tlicii"  a|i|icai-aiici'  iijioii  tlif 
chrsl  ami  alnloiiuii,  uiih  rallur  aljiimlaiit  new  croi.s  up  id  the  tli-vi'iilh 
(lay.  Tlic  rialiirr  ot'  llic  attack  uas  lliii>  c^lallli.-ll(  d.  I  Klcrvc-ccicc  .-ci  i[i 
licUVccii  llic  cIcvcMlli  aiiil  llic  luchlli  ilav  of  the  ili.-caM-.  (  oiivalcsccucL' 
was  thcrcai'tcr  iiiiiiitcrni|ilc(l.  The  alliiiniiii  iiail  ilisa|i|)cai'ci|  from  the  iiriiic 
'i|ioii  thi'  sixteciilh  ilay.  >vhilc  l.loo.l  aii'l  .iiiihclial  ca.-ls  ucrc  no  loii:.^^ 
(li'iiioiistralilc  atlcr  the  ciu'lilh  'lav. 

Willi  rcoai'ij  \n  llic  iinlisiiliial  .-yiii|itiiiii.-  I'liaractcfi^tic  of  l\|iliuicl 
I'cvcr.  tlic  iicciii'rciicc  III'  ciilai'i^ciiiciit  nf  tlic  .-iilccii  i-  i|iiilc  a.-  iVciiUciit 
ill  all  aiilifcviatcil  inil.i  or  aliMrii\c  ca-c-  a-  in  tlm-c  that  arc  coiniilctclv 
ciiaractcristic.  AccordinL^  to  iiiv  (ili-ci-vatimi-,  llic  ciilaro'ciiiciit  ot'  tlic 
-|)lccn  (icciifs  more  rrci|iiciillv  at  a  com|iarali\cly  early  |Krin(l — in  ilic 
lir-t  iluys  of  the  t'lAcr  or  c\cii  licfurc  it-  cornniciiccniciii — in  the  niilil 
ami  aliortivc  ca-c-  than  in  the  coiii|)lctcK-  cliaracteri-lic  (nic-.  It  ha- 
iiecii  e-|)ecially  in  these  ca<c-,  which  la'cr  |)iir-iii'<l  an  aliortixc  coiir-e, 
tliat  tlie  eoni|)laiiit  of  the  patient  of  leiiiicriic--  in  the  -picnic  rc^i,,ii, 
even   iiefore   the  on-i't    ot'  fc\cr,    has    leil    inc   to   exaiiiiiie   the   siilceii. 

The  rosciil:e  -ci'iii  to  lie,  on  the  whole.  Ic-s  profii-e  and  lc-<  con-tant 
ill  the  alilireviateil  ca-c-  than  is  the  ciilarycineiit  of'  the  -piccn.  In 
some  eases  they  ajipcar  rcinarkalily  early,  diiriiiir  the  tir-t  few  dav-  of 
the  I'cNiT  ;  while  ill  other-  their  prc-eiiee  is  -yiichroiioii-  with  the 
eiilarircmciit  of  the  -plceii  or  shortly  afterward.  Xot  rai'elv  their 
apiicarance  is  delayed,  and  -oinetimc-  tliev  appear  after  the  fc\-cr 
lias  siil)sidi><l.  I  have  even  in  a  iiiimlicr  of  iii-tain-es  oiiserved  the  (ir-t 
roseola'  only  after  dcfcrvesccnci',  on  the  cic-htli  or  the  iiiiitli  dav  of  the 
diseas.  ,  therefore  at  the  time  when  they  would  have  appeared  in  ordi- 
nary, eoiiipletely  developi'd  ca-es.  Complete  alisciice  of  th,.  ro-eola' 
seems   to    me   to   lie    more    frcipicnt    in     the  alihreviatcd    case-    than    in 

tlio-e  pnr-nintr  a  rciriilar  i-oiir-i — a  circiini-taiicc  that  coniriliiite-   i 

small  dci^rce  to  the  increa-cd  dilliciilly  in  diai:no-is,  rnii-nal  profusion 
of  the  cxanthcni  is  rare.  Imt  the  ea-e  prcvioiislv  referred  to  (p.  -Ji'ti) 
dcmoii-trate-  the  po--il)i|ity  of  ir<  oecnrreiice. 

Siidamina  ar im|)arati\'cly  rare  in  ea-cs  with  relativciv  low  tem- 
perature, lint  I  have  often  oliserved  tiiem  diirino-  the  period  of  deferve<- 
eeiice  in  alxirtive  eases  with  lii^li  and  l()nir-<'ontiiiiie<l  fever.  M<neoi'ism 
is  Ireipiently  aliseiit  in  I'ases  of  mild  or  very  mild  character,  and  is  <rn\- 
t-rally  slii^ht  when  it  occurs  in  al)orti\e  typhoid  fever.  Characteristic 
•  liarrlici  aiipeai's  to  lie  less  common  in  these  than  in  the  well-developed 
c'a.se.s.      As   ha.s  rej>«ULtlly   bw'ii   pjiiitcil  out,  this  ab.st'iioc  of  diarrhea 


'Sli 


.FjJ¥  r 


;502 


T)  rimii,  [ i:\i:ii. 


■    •»i«'V  ■ 


i^iluranv  Wn,..    „n,  |,n,v,.  „m,-i,  uiili  n  triviir,.  t,,  ,|„,  ,|,..,vr   ,,f  .|,.v,.I,,|,- 

"I'lil  nf  tl„.    -|„vili,.  ii,i,-iinal   Ir-ioM-.       On  il,,., trarv,   In  -.,„nr   ,■;,-,.-, 

"In.li  appaivMlls  allnr.l  ,„,  .^mnn.l  Inr  anxin^.lhr  n„,.|  niMl,H,-al,l.' 
Hirpi-i-r,  aiv  ,A|i,.ia.  nr,.,|,  ll.r  in-lan,v,  -n.l,l,n  ini,-iinal  In  niorrliau,.  ,„■ 
|iii'iliiniii<. 

lii.^T  snrh  riivum-tanr.-  I  l.av  s.,  ,.  ,.Titoi,itis  .„■,„,■  i„  ,\]iVrn~ul 
I.TMis.  In  a  l,.u  .;,>,-  n,  ulnr!,.  .iiirniL'  atlark.  „f  ivpl.ni.l  I,  w  r  of  ,niM 
"  ■  'natamrM, .,,„,„.  in  ,|..  ,i,l„  ,lia.  l„-,.a  u  H 1,  ,„  nu  phlni,-  ,.xa,lal,. 
ap,  ,.r^-!.  ih,.  ,,,„,>,.  ua~  ivIalu.U  tavnral.l...  (a-.-  Ita:al  vvrlnrMne 
|..T.:.„nl,s  i,av,-  1  .m  nuni  ,.„:,.,.  ,n  ,,;,-.■  L'l't;.  Su.l,!,,,  inl.-linai  F„  n,nn  kr^e 
!>l.'  inav  r„i,v,Tl  rniM,  |„.rl,a|.~  aruLulamrv,  , .,>,-,  n,i.,  mtI..,,-  ,,n,..  |  ]rne 
«rn  nisia,,,-,..-  „l    tins  kin,l  in  u  In.l,  ,1„.  ,„Vu>n„,,    „r  inuMi„al   Ian,..,  rl,a..e 

pivf  Hi,.  1,1-M  M,L-v.M„,i,  that  tv|.|,..i.|    l,x,r>i Li    I,.     l,„,k,..|    f..,-       <>,„.,> 

'">■  '"",";""■  ='  ;."^'"  '■"■!>  v,.a,>  .,1,1.  a.^  a.inn,,.,!  „„  a,,..,nnl  ..f.MHl,i,.n. 
s.'V,.rr  l,l,M„lv  .j.ai-rli.a.  uiil,  a  ,lia::n...-,>  ..1  .ln,Ml.„al  ul.v.-ali.a,.  It  ua. 
siMtc.l  tiiat  i„.  I.a.i  l,..,.|,  ,|uiu.  |,.a|,|,v  UvU.rv  tl,..  n.rnnviic..  ,.f  the  a,-,i'. 
.I.ni,  ai,.|  l,a.l  .■..i,i,,,n,  .1  al   I,,.  su,vk  witiiniit  iiil.riai|.tinM.       A   Tru  ,lav«  f.,!- 

'""■"-  l"^;"l'N,,-M.,„,  all,.,.  ,|„.  1,1 iy  .|i.,.l,arLr.s  l,a,i  l.tn  n|,la,v.l  1,;  tl.n, 

i..a->.,U|,-lik..  >t....|-.  il„-  l,n,|„,al,nv.  «l,i.-|,  .,n  a.ii,ii>..i,,i,  l,a,l  l.ien  -„!,- 
nonnai  n.so  u,  ti„.  .v,,,!,,:.'  t..  ::u  (  ■.  Ti.is  ua^  r.,il,,u..,|  |,v  ivn.i.unt  I, vr 
ot  nmd.-ralr  >,  v.  ial>  l.,r  a  |,.Ti,„l  ..fci^^ht  ,ia\>  with  .icrlinJ  ..f  tin.  i,.„.|  ,  ,-a- 
Un-c  l.v  ixM.,  11„.  MK-|.„a.,n  liial  liic  ,,,n,iiii,.n  «a>  nn,.  ,,f  tv|,i„,i,i  l.-vri'ulij, 
h.;mnrrl,a..'r  lV.,in  tla.  I,.,u..|  ua>  r,„„|,|,  iclv  v.  rilicl.  l„n  .,mI  v  u  I,..,,,  aft,,- an 


afclirilf   iiitirval 


i.t   (level,    ila\>,  a   sfVcfc    rfla|..>.e  ..t'  till,',  ii  ,lav.-'  (I,i|-atii. 


"••<Minv.i,  uiil,  .•,,la,-L'rine„t  ..f  il„.  s,,lr.i,.  ,li.-lii,ct  n..-c,,la',  an.l'  a-aii,  uil„ 
tlilii  M. ...].<  In  a  -,.',.n.i  caM^  „„.i,a-  i,,_\  .,l,M.rvati,.n  in  \^|,ic|,  the  h.  lu- 
..rrhii-e  ha.j  ...•.ainvi  afi.r  an  in.letlinl..  illne.^s  nf  sev.a-al  .lavs'  ,l„ratinn 
Mll.-n.l,..!  XMtl,  sliL'lii  i,^,■,■.  a  f.illv  .l.-v,.!.,,,,.!  relapse  e„nli,-„,e.l  ilie  sn-,,i.-i„.l 
".'  '"^  '^I'l'""!  "H-n..  (  ases  ..i'  niij.l  an.l  al,.,rlive  tvphni.l  feve,-  uiil,  intes. 
tmal  lH.n,..rrha-,.  aiv  n„„ii,.,,.  ,|  ais„  \.^  1  .iel  ,  n,;.' ■-ter.  u  h„  .ates  MHiilar 
nliservatinns    hy    I..Mii-      ami    \  allin,' 


-:^ 


F)itT,i^e  l,r.,ne|;iii,  i-  n.,t  ratv  in  ea^e-  ,.('  al..,iiive  ty|,l„,i,l  fl.ver,  a-  is 
fvi.lei.t  tn.m  the  .■!;,, i.'al  l,i-t.„i,,  aliva.K  .lelaih'.!.  an,!  I  ,,,nH,l,r  it 
"lie  .,f  tlie  in,,~t  valnal,!.'  ,lia-n.  ,-tl.'  -yni|,t,.n.-  if  it-  ,,n-,-i  ,^11  l,e  .-h..wn 
fo  have  ,,e,airivi|  Hniiillain'..ii--ly  with  tlie  n>i,aiiiin-  sMn|)t,,ni-.  I'm  ,i- 
nioiii,.  .•,,tni>li,-ati..iis  hav.^  ,K',airrv.|  in  my  e\|,..i-i,.|i,'e  with  exiivine  i-arity 
m  ."i-e-  ,,f  alM.i-fiv  ly|.h.,i.l  i;.v,T.  C.Mnplii-ali..,,-  an,l  s,.,,!,  1.  l,„.al!/eil 
ill  other  ..I'-i, IS  at-..  II,,  I,.--  ratv  in  the  al.breviate.l  li.rin-  <,f  ivplLu,! 
<''Ver   than    in    tl nlinars-    f..i-in. 

With  ivfeivncv  t,,  .■.,nvai,-,,n,M^  it  lias  l,e,ii  >iate(l  tiiat  in  e..rre- 
j^Jxitid.Mi.'e  with  th..  mil, hi,--  ,,f  th,>  -.yni|.I.,ni-  it  i-  liv.|,.,Mitly  ivin;;rkal.ly 
slx.rt  an,l  iin,',.inpl!,- at,.!  an,l  all,n,l,.,l  with  .■.,n-i.|,.faM,'  i„.,va-e  in 
vv,.i-ht— ,||,.|i  l„,y,in,l  tlie  pivvi,,!,-  w.iuhl.  '!'!],■  ,-a-,  -  ..f  -.v,!,-  ,,n-,l 
:i>„l  ,arly  hi-h  fevia- are.  Ii,,wever.  ,,||en  i;,ll,,w,.|  l,y  ,|nit,.  a  l,.ii-  |,eri,„l 

'  ^'■''-  '•''■■  '''■  ''■■  !'•  ■'--■  '  An-/,.  ,',■„.  ./.■  .1/,,A,  X,.v.,  1^73. 


^-^:  *.^^^ 


**,^_r^fc-,ir'a.-^i^"=P^J   :_-*  ^y*-f:f>^t-^'^ 


1M/.7.I //oA.s    /.V    s)  .V/'/'*.l/>    .l.\7;   (nri:si:. 


303 


-iC  convalc'MviKv  Willi  ((.ii-iilcnMc  .•Miariaii.iii  ^ii'l  r.illi.r  -l<,u  ivMnra- 
tiiiM   <.)■  till-   |pn\i.pii-    I"m|\ -wiiiilii. 

It  I-  \M>itli_v  lit'  (  -|M-.i,il  III.  riiiu])  tli.il  llic  riiiM  ami  aKorliv,-  ra-i  -  aiv 
lollowcil  li_v  n<ru(|i -cciK  ,..  and  r,  la|.-.~  uiih  iiarlifiilar  rir,|iirii,  \ ,  p,,- 
sililv  uilli  j:i-(a!iT  t'iV(|ii,iic_\  ;lian  ih,  -a.iv  ,a-r~.  ||,  aiMili..:,,  tin. 
sci'.Jii.j  ii-_v  altark-;  arc  -viid'allv  iiiwiv  .ntcii-r,  ol'  i.,ii-,.r  (JmaliMn.  ami 
iiKUc   cliaractrii-ric  lliaii    llic   |iriiii.i-y  .it  icL.      Thii-,  il    i-    iiui    ran-    Hn- 

tlif  iialiiiT  nf  a  ca-c  |.>  lie  ..li-mr ■  altii::..||irr'  iiiirtT<,-iii/,  .1  (liirin-  ilic 

tir«t  f.lirilc  |icii.Ml.  and  m.t  in  lir  \  icwni  in  i|,  |iiv.|)fr  li-lil  iiinil 
the  ucrni-iviii'c  ,,|'a  niap-c,  willi  il-  rhaiailci  i-tir  -\  ni|ituiii-,  I'd-rdu', 
I'liiarirniirnt  df  the  -|iiccii.  etc.  In  nut  a  liw  in-laiici-  ilic  atlack  is 
ii'.t  t.a-ininal.,|  uiih  a  >in-l,.  ivla|i-c.  I  have  ( J.-.tv,-,!  iww  an,!,  sen 
tiircf   ivla|,M.-   an, I    iv,TUil,-,Tn,v-    'Ml. .win::  a    niilil    |)iainarv   atta,'k. 

Witl.  n-ai-,1  I,,  ill,.  i,,ial  ,|n|.al.  ,  ,,ftl„.  inijuTliMlly  ,l,.\  ,.1,,|„.,1  .-aM-, 
th,.  l.ivvity  ,,f  th,.  atn,.k  is  as  wa-  ,.in|,lia-i/,.,l  at  tli(.  ,)iitMl,  il„.  in,.-t 
'■liara,.|,.|iMi,.  t;.aniiv  ,,|'  ilics,.  ,.a.,.s  A  ,inrati,.n  of  tlic  ti^v.-r  i;,i-  in,.r,. 
than  t,.n  ,,r  luvlv,.  days  i.  ..xtivni...  ()ri,.|i  ,.n,.n!.r!i  it  i.  ,,nlv  lV,,ni 
thiv,.  t,.  -i\  ,iay-.  \Vli,.n  ,-,,n val,.-,.,.n,.,.  i-  rapiil  aiiil  uiic<nni,ii,.atc,l, 
n,,t    a    I'cw  ,a-,>    l,.rniin:ii,.  w  iihin    tin-,,.  \v,.,.ks.  |,nt    ,.vi.n    ra-c-   ,,t'  ,,nlv 

''""■''■'•"   ''■'>■-■  'liiiMti..n   ,,r   -li.^iitly  I ., ,.„,..      ()„  ,1,,,  ,,,!„.,.  |,.,,„|_  .,", 

til..  iM.-iniiin-  ,.f  ,.v,.n  niil,|  ..a-,.-  ||„.  |„,--il,i]ity  ,,f  ,i„.  ,.,„„•-,.  |„.i„^r 
l"-"lni,.|,.,l  ,,!•  ,.,,iua!,.-,.,.|„.,.  l.cin^r  |„.,,|,,n;:,.,l  ,,win;,rl,.  ri.(.ni(l<.-,.,.n,.,.-  aii,l 
rclap-,-  nin-t  hu  kt.pt  in  niiii,l  in  ..\pf(.>siii-  an  , .pinion  as  t..  tli,.  pr,,l,- 
al)l(.  ,lui'ati,in. 

Symptoms  due  to  Typhoid  Toxins.— Alil.,.,,-!!  alni,,-t  ail 

writ,.!--  ul„,  |,av,.  -tn,li,.,l  tl.,.  alypi,.al,  al,liivviat,.,l  i;,nrw  ,.r  typli,,i,! 
lever  have  ..vpr,--,.,!  an  ,,pini,>n  a-  i,,  th..  , .,,11,1111, ,ns  att,.n,!iii-  it-  ,1,^,1- 

"l"'"'""-  " '"'  'I"'   tli,.,,fi(.s    l,ith,.|.i,,    put  t;,nvaf,l  app,.a.-s   t,>  I.,.  snUi- 

cicnt.  It  i-  ,.1-y  t,.  siy  iliai  th,-  ,.,m,liti,,ns  are  ,l,.p<.n,l(.nt  iip,,n  ilio 
a,  ti.in  ,,(•  atl,.|iMat,.,l  hai-illi.  ,,r  iip,in  a  ,|iiantitaliv,.ly  sli-ht  inl^eti,,!) 
l,"Ti,nh,'  n,  yrlUr  ,1ns.-  ,,f  th,.  Fn.iM'hi.  ,.r  up,,n  -li^dit  -n-ccpl  ihijit  v  ,,(' 
the  ,)r-ani.-in,  nr,  ,iii  ih,.  ,)ther  haii,l,  np,.n  inark,.<l  ,.|i,iiinaliv,.  ..apa.'itv 
«>n  the  part  „f  the  l.,Mly.  Alth,,n-h  th,-,.  -tat..in,.nts  may  e,,ntain  inn.'ii 
tliat  is  trn,..  M,  far  a-  actual  kn,,w|,,|.je  i-  e,in,.,.ni,.,l.  tjieso  hvp,,the-es 
are,.niy  fWinnilai,..!  pn.hkn,-..  Th,.  -,,lnii.,ns  mn-t  \>v  i:ain,.d  step  l.y 
stej)  hy  ni.ans  ,,r  jiain-takiiiu'-  experiin,.mal  inve-tiL'-:iti,in. 

<'"ii-i,l,.rini:  th,.  ,|n,.Mi,,n  Inim  thi-  p,,iiit  ,,|'  vi.'w,  ,.n,.  inav -,, -till 
further  with  r,  i;.ivn,.,.  t,,  the  pn„ln..|i.,n  ,,r  c-rtaln  ,.i.-,.s,  aii,l  a,-k— May 
iK't  .all  the  p,.eiiiiar  -ynipt,ini  in  luiinan  l),.i!nrs  |„,  in,ln,.,.,l  hv  th,. 
aeti,,n  ,,t'  typh,,i,l  toxins,  jn-t  as  ,.an  1,,.  ..,,nc  e\-p,.rini,.ntally  in  anhiials, 
as   has   |,e,.„   d,.ni,,n-trat,.,|    with   <.,.|tainty  hy  Frilnkel   ami   .Smnwiids, 


\  !{ 


iilp 


:iii| 


/I  rii'iih  1 1  \  1 1:. 


^I^'l 


i\ila-atip  and  \\  a--iiiiiaiiii.  >ii-.r|]iiiii,  r.aiini_raiMi  ri,  ami  ..i|i,r-'  (  H. 
'ImiiI,|ci|I\  al>!lli'laiit  |".--iMlil\  ari'l  m|,|..,i  liiriil  v  aic  allo|-,|r.|  |,,|-  -ijili 
iiilM\iiatiMii.  It  w.piiM  |pr  iHic--ai\  ["  i.iii-iili  r  ill  -iirh  ca-c-  r-iMciallv 
ill'  a.  ■(  1. 1.  I  Hal  iiiL;i  -linn  ,,1'  -ivall\  iiili  ri,  ,|  :i  n  id,  -  ,,|'  li..  „i  in  \\  ||i,.||  1 1„, 
iipiilainiil  liacilli.  aln  r  lia\  iiii:  L'ivall\    niiill  i|>li(d,  liad   Ki  .  n  d, -i  |-,,\ ,  ,|  i,\- 

l"i'iii:i.  ' I^nrj.  I'akiiii',  and    iIk    lik.',  and    tin  ir  Iomii-    alone  rirnaiiii)! 

aiii\ ,  . 

1  liat    tln>    liiiniaii    oiLrani-ni  —  |iiv-M|)|m  .-iiiu-    l:i\(,|-aMc    |i(i-»iiiial     and 

external  e.,iidiii,,ii read-  l..  ilie   intiniliii'iinn  i.T  -mli  |M.i-,.ii-    d^.e-  nut 

a|'|'ear    to    nie    l.i    lie    in    ilie    -lijliie-i  d(  - ive  doi il ,|  fu | .       ,\-  a  nialtei-ol' 

t':i''-     I     lia\e    r.  |.eal.  illy    iili-ii\ed    in    tin-     emii'-e    nl'    I -e    :iiid    taniilv 

I  ndi  iiiie-  diiriiiL'  |ieriiiil-  w  lien  ty|iliiiii|  l'e\  ■  t-  wa-  -evefi.  in  addilinn  Id 
iliaiaeti  ri-lie  e  i-e-  lit'  \  ar\  iiii;-  .-e\  a  ril\  .  ullier-  \\  jm-e  e\  planal  ii  ai  \\a~  inn-l 
reailily  tiirni-liid    li\    llie  a--iiiii|iliiin    ><{'  llie   e\;ilii-i\e   aetinii   ot'  iM\in- 

ll|Mill   llie  iir^riiiii^iii        TIk  -e  Were    11 H  lie   iiT  le--  -e\  el'e,  al    I  inie-  l|nite   -eV  ere, 

ea-e-  w  liieli  M(  III  ralK  iMviinvd  in  yuiiiiLr  iiidi\  idiial-,  -la-vanl-,  eiHik-,  etc., 
and  had  a  diir  ilinn  iil'  tVnni  t  w i  niy-liiiir  In  |iir!\  -eii.dii,  and  iml  inure  than 
-I  \  I  Ills -two.  hiiiir-.  The  |ialienl-.  enni|ilained  i,|'  -e\eie  lieadaehe  and 
\eiii;^ii,  -hiMiiiii^-  jiaiii-  in  till    -aeral  reLdmi  and  in  the  |i.\Mr  extiemiiie-, 

with    IlialLed   elllanenll-   and    nill-elllar  ll\[iere-t||e-ia.         I'liev   Were   re-tle-s 

and  -li  e|il( --.  and  Inward  tliee\  ■iiiiii.'- and  at  iiiLihl  e\  en  -liLrhllv  -tn]i(ir- 
nii-.  Aim. 1-1  all  the  jiaiieiii-  e^hiliited  frmn  the  iiiit-et  marked  nan-ea 
and  \llnlitillL^  In  addition  In  tnlal  anmexia  nr  e\  en  di-ifn-i  t'nr  all 
tiind.  they  -iill'ind  frnMi  liiiniiii;:  tliir-t.  The  tniiirne  \va-  liea\il\-  coaled 
tlirnU'jhniii.  a!  lime-  tn  >iicli  ;i  (Icirrcc  ill  tlic  ciiur.-e  nf  a  lew  hours  that 
il   a|i|ii  ared  a-  it'  Imiled. 

At  the  -aiiie  time  -e\ere  diari'liea  oecnrn  i|  in  inaiiv  v  iihoiit  tlic 
characlcn-'ic    pea— oiiji-like    color   ot'    the    -tool-.       (^iiitc   excejiiioiiallv 

di-tre--iiiL'    'ene-mn-    wiih    niiienii-   and    lilnnd\-  -ton!-  wa-   oh-crvcd a 

nianit'e-tatinii  thai  recalled  |iircilil\-  tn  niv  iiiiiid  certain  Ic-inn-  i\\'  the 
lai-Lie  inte-iinc  iiicjiiced  e\|periiiiciitall\  ill  animal-  lp\-  hhmii-  of  t\|ihipid 
I'pxiii-.  In  the  inaiorily  ot'  ca-es  llieri'  \\a<  sli^rhi  iiietiipi'i-in.  I  lia\c 
olp-p  r\cd  enlarL'pinenl  of  the  -|p|eeii  in  a  nninlur  of  in-tanci-..  Imt  ha\(' 
ne\er  -I'lii  ro-eofc.  At  timi-,  in  the  conr-i'  (pf  from  twcixe  tip  lii^litci'ii 
ho. if-  alter  the  on-ii  of'  till'  di-i-a-c.  there  wa-  modiratp'  allpiiminuria. 
uhiih  in\arialp|y  -non  -ulp-ii|id.  with  a  -mall  nnmlppripf  hvaliiie  tnlii.- 
ca-l-.  IpiiI  without  other  characteri-tic  niipriihip!o!.ric  cli'iiieiit^.  anil  iiar- 
tieiilarlv    wilhipiit    lil 1. 

(iciKTally  the  ca-c-  were  atti-ndcil  with  fever,  yettiiiL'  in  \\\i\\ 
rp|pp'ati'(l  -en-atiipti-  ppf  ehilline--  or  a  ilelinite  chill,  the  tem|)i'ratiiro 
n'achiiiL'-   -I'l     ( '.  in  tli(>  InlprIlillL^  and    at    lime<    In'   ( '.  (pr  aliovc    in    the 


riA7l77'<Vs    l\  .S)U/'/'M/v    i.v/»   cnriisi:. 


;{(».■) 


•  •vcnitiL'.       I    li:i\.'   lint  a-  yrt  (,I.-.tv.,|  .halli  :i-  a  r.  -iili  of  ihi-  Criii  of 

llic   (li-ca-r,  alllioii^^li    tli( mlilioii    in    -,,iiir    in-laii.-.  -   a|i|Mar.-,|    ,,iiii,. 

alarlllir|._^  and  iiii|,i(-«,.|  rwn  llic  la\  rue  n  a-  a  -late  >,f  |.n.i;,nn.l 
ini<.\i(atii)n.  'I'lir  -iili-i.l.ncr  of  ih,'  -vni|pt(itn-  ncm-  in  iIh  ioiii>.'  of 
ll-utti  tw.iity-tuur  In  -cvcfily-luu  Imur-.  at  llic  lit. -i.  and  i>  alino-t 
;'!\vays  :i-<(h  iatcd  wiili  rapid  d.rlini^  in  !lic  l.in|M  i-;iturc,  a.<-.,ni|iarii.d  l.y 
|>rulu-,.  -iwcalin-.  Kv.n  alt.r  ih..  disi|,|.(aran,r  <,{'  ali  cillicr  inorl.i.'l 
>.\in|.tnMi-  there  (, 11,11  i.niaiii  inui-nal  |iri.-lraliun  and  larr'.MKir,  wlii.li 
l<f.'|.   «uni.'   paiient-   in   li.d   ,,r   in    tiicir   muin-   li.r  in. .re  tlian   a   w.ek. 

Sncli  in-tancc-   iv.|nin'  oidy  t"  lie  inciiiio 1   in   order  to   remind   otlur 

pliy-ieian<  of  -iiiiilar  ca-o  in  their  own  experieii.e.  i'"(,r  tiirtiier  -Indies 
it  would  cerlainly  he  worth  wiiiie  to  eoinpaiv  airain  lii..  ehnieal  pietnrt; 
olwerved  in  hninan  hein^r,  witli  the  iVMilts  of  the  exi.eriiiiental  acti.ui 
<>!'  toxin-   in   animal-. 

To  what  extent,  if  at  all,  tlio  short.-t  of  the  atypical  e:i-<s  de-cnhed 

in  the  preeedinir  -eetion  depend  nix.ii  the  action  ..f  toxins  alone  or  n| 

•'  '■""'•'i'i:'ti f  ihi-  with  that  of  att<'nnatc<l  enltiires  ;    wiiether  .••■rtaii. 

especially  violent  severe  ■■a-es  ,,f  sh,.rt  .(pMr-e  are  |H,-il,ly  to  I.e  eoti- 
si.lered  as  examjiles  of  ••  toxin-typli,.i.|  fever,"  arc  (|n<-tions  which  mn-t 
i;.r  the  present  remain  nn.l.Ki.l.il.  h  appears  .piite  intere-tinL'  to  nie 
111  this  .•oniiecti,,n  that  ( 'liantemc-e  '  found,  on  puncture  of  the  splcn 
m  ca-".-  of  ahoHivc  typhoid  f^ver,  that  the  -picnic  juice  wa-  fnv  from 
tlio  hacilli  of  KI.erth,  and  :.<■  attempt-  to  explain  this  rir.nm-tanc*  l,y 
iissumiiijr  that  in  the-c  casts  the  bacilli  peiicti-.ito  less  deeplv  into  the 
tissues. 


THE  LATENT  VARIETIES. 
Ambulatory  Typhoid  Fever ;  Afebrile  Typhoid  F(    er 

Anion-  tlie  latent  varietie-  mi-ht  he  ineiu.hd  al-o  th.,-e  eases  in  which 
the  attack  of  typhoi.l  fever  he-ins  and  .•ontinue-  amid  >,.vere  hut 
•inn-ual  -ympton,-,  so  that  at  the  on-et.  and  not  rarelv  thnm-diout,  its 
nature  may  I,,.  unreeo-uiz,.i— ncphrotyphoi.l,  pucumou  phoid,  pjeuro- 
typhoid.  typh,,i.i  fever  MttiiiiT  in  with  m.nii:-iti-  or  p-vchos.s.  Tlicso 
varieties,  howcv.f,  will  I,,,  more  appropriately  .•on-idcre."l  .at  >o,ue  other 
place.  Tiiosc  eases  will  he  eou-i.lercl  a-^  l.el.miriuir  t,,  ,|„.  \,^^,.ut 
v:wieties  in  th..  >trict  sens,,  of  th,.  word  that  are  .•hai-aet,  rif..,|  hv  al,>..nc,. 
or  nul.ln.ss  of  the  fever  or  -uch  sli-htne-  of  other  svmpfom-' that  th,. 
patient  is  not  ivally  ,.or,s..i,,ns  of  tlie  exi-tcnec  of  a  -.'rion-  di-,.rd.a-. 

Ambulatory    Typhoid    Fever.— Th,.  ,piaii,u.atio„    amhnlatorv    was 
introduecl    l.y    ( ;ri,.s.injr,,,.,    and    is   -..nerally    eniplovcMl    ..-p.riaily 

'  Tm:/,'  ,!,■   \Uid  .   ■..  77!.  ar.i!  Sn-.:    :..:.'.      \..,       lie:,-. 


in 


:'tC'- 


^: 


■MW, 


lyrii'iih  1 1  \  1 1: 


(n'tril.inx.         In     I'l-.iin  .■.    wImi,      il-    i  \i-|,  nc,      i-   :i.tll.ill\-  .Irtliiil     li\    -( 

u  rile  1-  (  l'.|-oii,iii|(  h,  ih.  i|ii  ililii  Mii..|i  liiinil.  ulinli  in  in\  n|iiMinii  i-  I,.-, 
ili-liiirllv,  (  l,..ui-.  <  iLpru.  I,  iiinl  ..(||,r.i.  i-  riion  cmmiiiimhK  .iiiiiliiVnl. 
■|  111    (jiialilic.iliori    .iiiiliiil  i|.,|-\    .i|i|ill.-    ii:iliil:ill\    |..  ih,'  iii,,-|    i-.i|i~|iirii<p||- 

•'■mil'.'  ..f  ill,     ilniii'.il    |,i,iiii-,   :    ill,.    |i;iiii  111-  ,| I    -.,  I,,  l„  ,|,  liiil  ,',,n- 

Iiiiiii    iiH,iv  ,ir  1,--  riill\    ill  ill,-  piir-iiii  ,,r  ill,  ir  ii-ii:il  ,H(i'|«:iti..ii~.      'Iln- 

|,|V~I1|,|„.-,-      |||;||       ||„        -\  I|||,|,,||l.     ;||V     ill       ill,       ,.l|l-,|      :|ImI      I  I  II,  ,1 1- I  |,  ,1  it      l||,' 

'•"III'-,'    -,    -Ifjiil    lliil    ill,-    i,,ili,iil    liilnr    ,1,1,-    ii.,i    ,■ jiLiiii    ill    iill    ,,r 

iiiiik,-  liiil  lilll,  ,,!' hi-  ill-,!,  Iiii,,|  ,li-,  ,,iiii;,|i.  S,,iii,.  |,.ili.  ,il-,  it  i,  inif, 
.-iillir  hi'piv  ;  lli.\  :iiv  ,-,,ii-,iMii-  ,,t  l„lii;j  j||  im,]  (;\,.ri-|,.  'I'Ih-v.  |i,,u- 
<\,|'.  i,-i-l  ill,  ,li-,;i-,..  iiiiij  III  ihi-  ill,'  ,iii-,iiii-iiu,'i|  li\  tli,ir  tii,iii|-., 
-III'''.  :i-    ii"i    i:ii' i\   ,„',-iii-   I,  r  iimiiv,  i-iilil,-   ,\Iii-iiiil    ciiKlilhiii-,  lli.v 

illV    lr,',|ll,llll\     ,',i||-i,li   r,,|    ,1-    -iliillliil,,!--   ,,|-    lil;ili|i._;i||.|V. 

I  I"'  '"111--,  ,'1'  ,  \,  111-  ii-  ,  li,  ii,,|  ri,.iii  ill,  ,  ..m|.l:iiiil-  ,.r  til,.  |)iiti,iit 
111-  del,  riiiili,',l  -I|lp-,,|||,  iilly  iin  ll-liiill\  ii-  f,.!|,.\\-:  'I'li,.  ,|i>,;i-c  ;;,liir- 
iillv    ii.-iii-    l:I':i'Iii.iII\  .    iii-i,li,.ti-l\  .  ill    tiiii,-  wiili   ii    li.liii^'  III'  .111111111'", 

xviiiili     iiiiiy    Ii,'     i,|i,ii|,  ,1     ill     ill,'    liiiili,  r    , r-|.   ,,f    tli,'    ;itt:ick.       'I'lic 

|i:iii,iii-  <',,iii|>liiiii  .,r  |ir,.-r, --i\,  |\  iiii'ivii  _,■  liiiiuii,,!-,  ami  ;in'  |ir<i— 
trill, -,1.  ,'-|i>,iiill\  |,.«;iid  ,\iniii;^.  'I'jii'v  lir,  iit  \\,.rk,  iind  diiriiiir  the 
<Liy  r,  iilil\  liill  ii-l,,|i.  wliil,  iliii'ilii;  ill,'  iii-lii  ili,'\  iii-i'  liiit.  |„  i--|iii'- 
ini:,  -l(','|il, --,  ,ir  ,li-iiii-lH  ,1  i>_v  liiulitt'iij  ilrc;iiii>.  'I'lic  111,,.  I„i-,,m,- 
I'lili-;  the  rii,  Ilia!  -lal,'  i-  ili'|ii',»('(i.  at  linn-  irril.-ililc.  <  n  ii,iiill\-  llic 
t,'iiLriir  i-  >,inii'\\  liiil  (■■•ali'il,  iiiiil  iilni,'-l  iiluiix-  ihc  iiiiiictiti'  i-  |,i-l  iiiiil 
till'  -111-,'  ,,t'  lliir-I  iii,i',':i-,',l.  lrr,'L;iilar  ii,'lii,ii  ,it'  llii'  li,.\\,'l-,  w  iili  lliitii- 
Irii,',',  iilirriiiiir- w  iili  ili  iniii'ii.  ,ir  iIh'M'  i-  |m  r-i-nnt  i',>ii-ii]iati,iii.      .Sunr 

liiitiriit-    ipliiin    ,,|'    -liirlil    aiii;iii,i-i'   -\  ni|il,iin-,    while   otlirr-    rxliiliit 

liniiii'liili,-    iniinili-liili,.ii-   iiinl    iM-licM'   lli,  in-tls  t-   tn   he  siitl'criim    t'nini 

a  Ill  "  ,ir  triim  inlliiiii/a. 

'I"(ni|irnitiin'-nli-i'r\  iitiiiii-  arc  natiiralU  niiiilr  iiTi'Lnilarlv,  it'  at  all, 
in  |iri\iiii'  |iriiriii'i',  in  lii  ,-  nl'  :iiiiliiiliiior\  i\|ilii,ii|  ll'Vcr;  iinil  a>  llic 
patii'iit-  ari'  >rlil,iiii  -ml  ii,  ilir  Im-jiiiiil-,  ii  tliiirniii^!i  -tinh-  i-  as  vet 
waiitiii:^'.  Ai'iiinliiiL''  tn  in\  oli-ri'vatinii,  tlir  tciii|n'nitnr('-riinr-i'  iii:iv 
1)1' of -i'\  cnil  \  arii'lii'-.  'I'lni-.  tliii-i'  niiiv  lir  -iiiijili'  n  mittciit  i'cvcr  at  a 
l(i\v  li'Vi'l,  -11  lliiit  in  till'   nmniiiiLr   tln'    Ii'in|>i'ratiiri'  ri-c-    lilllr  aliove  the 

nnrnial.  ifat  all.      (^iiiir  i nmnly  al-n  ii  rrirnlar  vai'iatii>n>  ucciii',  with 

a  >ii(|ili'ii  cli'Viitiiiii  iliiriiiL:  llir  ninrniiiii  m-  in  tlir  niiilillr  nl'  the  dav,  as 
a  ri'-nit  of  cxrilinn'iit.  ii\  rri'MTlinn.  I'tr.,  nr  witlmut  iil>\ii)tis  ciiii.-c. 
Olliii-  I'ii.-i'-  |iiir-iii'  ill!  iili'lirili-  i'iiiii--i'  thriiiiuliiiiil,  or  ;it  Ira-t  Tor  -rvcril 
(lays.  An  inlrnnitlint  tilirilr  rmir-r  i-  Icii-t  roniinon.  in  whirli  (leva- 
tioii  of  till'  t,'ni|ii'ratnrr  iiKiy  tal<r  place  ilailv.  with  a  eliill  or  with  teel- 
iiiL'-  of  ehilline-.-.       ill    ii    niinlier  ot'  in-tancos    I    havt'   oli-ervcd   that 


mt;, 


I  \i:n  I i"\s  IS   N)  uri'i.Ms  .\.\i>  coi  /;>/■ 


.•;<i7 


iiMcli  r  -iirli  c'Mii(iiii,,ii.  ilii-  a-ii  Ml  Ilk,,  |,|.i(v  in.t  tnwanl  iM'iiiii^',  Imt 
riLrill.irlv  ;it  :i  liiiic  wli.ll  till'  iKilii'iit  i-  lr|..-l  ;|ili\,l\  i  iiM-:,j_r,.,|  ;  |t  j, 
llirK  f.  .rr  ill  rhf  ii.iliiii-  111'  ;i  ri:i(li.iii  {,,  cMciii.il  iiilliHiicc  -.  Tliii-,  I 
iii-;i||  ilic  cM-c  ..r  A  ]ili\ -i(i:iii  wli.i  iliiiiiiM  ;iii  all:iik  nl'  aiiiliiilaldiv 
l\|iliMii|  r.  .jiilaiiy  .xliiLil..!  Iiilliii<--  «iili  inaikitl  Ha  cr  alt<r  lii-  <uii- 
-iiltaliiiii-liMiir  ar  alxiMi  nonii,  «  liilc  •liiriii:;  lln  iiinaitiiiii'-  I  iiiii'  tin'  Iiiu- 
|irntlllc'  \\:i-  iiipi^  lal,  liuui  Air  nl'ii  n  i  ili-i  i  \  at  ion-  \mii'  inaili-.  AiinliiiT 
|ialiiiit    mull  r    my    rai-i  ,    an    alLTniA,    liail    lii-   allai  k-   of  liAir   in    llic 

rniiii:    ilniin-    iIh'    -i,.i,.|i-    of    roint.       Tlir    |iliv-iiian    n  lirinl    lo 

lirliiAiil  liiin-i  ll  -iillniiii^  from  malaria,  iiiilil  a  n  la|i-r,  «ii|i  iharailrr- 
i-lic  l,'m|..raliiri'-.iir\c,  iliarrlna,  ami  lo-iola  ,  .l.-ainl  ii|i  llir  natiliv  of 
llic  att.nk  ;  wiiili-  in  ilir  oih.-r  |ialiriil.  w  lio  xoiilinl  ivmarkalilv  iiiirli- 
lojoiiil,  ijaik.  lir.AMii-li-ivil  iirinr  iliiriiiL'  llii'  lilirilc  |ii  ri.nl.  [.aroWMiiai 
lirmoi^lojiimiria  wa-at   lir-i   -ii-|iirtril. 

1'       I'lil-r   a|.|i'ar-    in    aiiiio-i    all    ca-r-    I.   !"■    iviiiarkalp|v    fiv,|,|,.nt 

from    ihf    li.  uimiiir.f,    rrlali\<l\    ri'    -o   llian    in    t\  |iliiii.|    |iatii'iit-.  ulm 

li;i\<'  i; I"  '"il.      N\  lirilnr  ilirroii-m   oiiiu-  or  not,  I  iln   not    know. 

In  a  lon-iilrralilc-  immliir  of  |ntiint~  tlir  artioti  o|'  tlir  Inart  a|.|.car»  to 
!'•■  'Vfii  nioiT  ini-tal)lr  than  tlir  -tali' of'  llii'  liodx -iiiii|Mratiiri',  mp  that 
-oiiH' .'oini.l.iin  oii|\   of  atiark- of  |,al|,iialion.      'riii-  ;ihy-ii-ian  pn  vioii-|v 

rcfirivil    to    hail    liim-cif   ili  tii'lnl    iiitcrini-~i I'    thr    piil-i',    ami    had 

i-oncciv.'il    all    |io--ili|(.    hy|ioclionili'iaral   iilfa-  in   rr^r.iril    to    ii,  alth di 

no  -|H'i'ial  I'lianm'  in  ihc  heart  loiiM  -iii.-ii|ii(ntly  Im   tlcinoii-lratcd. 

Kvcn  at  till'  primary  fxamination  in  ca-i-  of  amlmlatorv  Iv|)lioi(l 
fiver  (li'-liiict  enlarucineiit  of  the  -|ileeii  i-  not  nirelv  foiinil.  Oeeasioii- 
ally  the  paiieiits  ihem-elve-.  ilinei  attention  to  tlii-  hv  eomplaints  nf 
aliiiormal  -in-ation-  ii,  the  |,.fi  liypoehoiiilrinm.  Iio-eohe  al-o  are  not 
iiifrei|nenlly  fmnil  on  earefiil  examination,  alllioiiuh  ii'enerallv  in  small 
nnmlier-.      I  have  per-onaliy  lieeii  .ihle  to  ijemoii-ii-ale  them  in   jiatieiits 

"li"' sniteil  mi'   in  n:y  otliee — onee,  f.r  in-taiiee,  in  a   vomie   woman 

trom  Kn--ia,  wiio  hail  lieeii  -eiit  to  Fran/cn-liail  on  aeeoniit  oi  "ililo- 
ro-i^  with  hy-terie  -ynipiom-."  and  lieeomiiis,''  iier-elf  donlitfnl,  had  eoii- 
'-nlled  me  in  rniif,-. 

With  rcirard  to  tji,.  ,oiir-e  and  the  diiralioii  of  amlmlatorv  tvphoid 
fever,  naturally  no  detinite  statement  can  Ix'  made  tlir  the  maji.ritv  of 
ia~e-.  riidoiilitedly  two  jirineipal  varieties  oeeiir  in  this  form  of  the 
disease.  '|"he  one  illeliides  the  Well-developed  eaxs  of'  tvphoid  fever 
of  il-lial  diinitidii.  In  tliese  the  disease  extends  over  from  four  to  six- 
weeks,  when  recovery  oeeiirs.  If  -mh  develi>|MMl  eases  iinex[M'etedlv 
terminate  latally, — as  niif  irtimately  not  uneommonly  oeeiirs.  partieiilarlv 
trom   heinorrha<:e  and  perforative  iK'ritoiiitis, — tliev  ofton  occasion  stir- 


:'i\ 


;50H 


TYViinii)  I  i:\i:n. 


■■"-ki.*  ■■• 


M^ 


■"., '    » 


jin-c  :it  ]>()-t-iii(>rt(in  cxiiiiiiiKitioii  on  accduiil  of  the  iimi-iial  (K'Vclon- 
iiiciil  and  extent  i>l'tlie  intestinal  legion-  anil  otlier  <liara(teri>tio  visceral 
<'lKinj::es. 

Tlie  Mronil  iri""ii|)  (it'  eases  ini.re  ehisely  appniximates  tlie  ediulitioiis 
]>i'e~eni  in  tlie  nn(levelii|>e(l,  mild  cases,  and  ini<:lit  (Minallv  well  liavo 
been  <lis<ussed  in  the  |>ieeediii;;  ehaptef.  I5_v  reason  ol' their  sliiirt  dura- 
tion and  the  eirennistanee  that  the  slijjlit  distlirlianees  rarelv  restrain 
the  i)atieiits  in  their  aeenstoined  oeenpations,  they  eertaiiilv  nften  cscaiM> 
recdi^nitinn,  e-peeiallv  when  they  ocenr  isolated  and  without  anv  dis- 
timt  eoiineetion  with  well-iK'velo|H'd  cas<'s  of  tV])lioid  fever.  Not  a 
tew  crises  of  "cold,"  "  anjrina,"  "acute  pistro-intestiiial  catarrh."  or 
"  iiiHnenza  "  may  heloni,'  in  this  s^ron]).  Other  cases  of  the  ainhtdatorv 
<>!)(■ — exactly  as  \,as  mentione<I  as  oeenrriM;,^  in  c:l-cs  of  mild  tvphoid 
icvcr — arc  recoir,,i/,.,l  ,„,Iy  when,  after  slijrht  .syiufttoins  have  hceii 
present  for  days,  there  occurs  a  recrudescence  or  a  relapse,  accoinpain'cd 
liy  rosiHihe,  enlarireuK  nt  of  the  spleen,  and  characteristic  intestinal 
sym])toins.  It  shmdd  he  ex])ressly  empliasi/.ed  at  this  jilaec  that  even 
the  a])])arcntly  mild,  amlmlatory  cases  of  short  duration  mav,  thouirh 
apparently  seldom,  reveal  themselves  l>y  intestinal  lieinorrliaue  and  peri- 
tonitis, and  terniinate  t-itally  therefrom. 

With  rey::ird  to  ap'  and  sex.  I  lielieve  the  statement  is  jtiMific.l  that 
amhulatoiy  ty]ihoi<i  t'ever  occur-  more  frcijUently  in  adults  than  in 
children,  .\mony  the  fmner,  in  my  experience,  the  yomif  and  older 
individuals  seem  to  he  ahout  c<|iially  pndisposcd.  I  havcc\<Ti  observed 
aiiilMilatory  typhoiil  t'ever  in  <leliiiitate<l.  elderly  individuals.  With 
re<raril  to  sex,  men  are  distimtly  more  conuuoiily  atrected  than  women, 
riiey  arc  more  resistant,  less  sensitive,  and,  amon<r  the  lower  classes, 
ot'tcn  secure  ivdief  hy  the  U:-e  of  alcohol  fn,ni  symptoms  that  would 
cause   (.tilers   to   take   to   their   beds. 

Some  persons  with  aniluilatory  ly|iiioid  fever  may  iierferiii  Piirprisinf:  tasks. 
A  salesMiaii  who  had  already  been  ill  hetwecli  two  ai  1  three  weeks  liad  dailv 
coiitiniieil  at  his  work  without  iiilerriiptinu,  jviid  had  walked  four  limirs  on  the 
day  of  Ills  admission  to  the  'iiospiial,  the  reason  for  his  coniiiii.'  liaviiifr  been  a 
slitrht  intestinal  lieiiF(irrlia,"-e  while  li-oiii;.'  about.  On  adinissioii,  enlar^-eiiient 
of  the  s|)l(Mii.  slii;lit  ineteorisni.  and  u  profusion  of  ros-eohe  were  donioiistra- 
hle.  Anotlier  i>alienl  under  my  care,  a  pilot,  t'orty-two  vears  old,  had  con- 
tinued ill  wrvice  uninterruptedly  lliroiiirhout  the  entire  journey  from  New 
York  to  HandiurL'.  iilthoiiiih  he  had  for  a  nmiiher  of  davs  suffered  from 
anorexia,  diarrhea,  occasional  headache,  and  vertiiro  ;  he  ha''  even  renif.ined 
almost  constantly  at  his  post  duriiiL'  the  last  storinv  davs  in  the  KiiLdisli 
Channel.  On  the  day  of  his  arriv.ll  a!  Ilaiiiburir  the  sudden  devflopinent 
of  svmptoiHs  of  rircui.isf-ribed  peritonitis  conipelled  his  entrance  into  ihr 
liospilal.  On  admissi<iii  he  |)resented  inodcrate  fever,  hut  no  other  than  the 
local  manifestations.      It  was  not   until   after   the  <iisappearaiice  of  the  peri- 


\.\i:i\ii<j.\s  i.\  sYMi'ToMs  AM)  (■(trust:. 


3(19 


lonitic  syniptiiiiia.  tu.lv.-  .lin>  at'tt-r  :i(liiii.-.-ioii,  iliut  a  iiuirkcii  rccriKicsciMuv, 
lastiii;:  t'oiirlffii  (l:i\>,  «itli  lii^'li  fever,  .■iilar;:eiiieiit  of  tlie  spleen,  aii.l 
ro.-eohe,  reiKlcre,!  eertaiii  niir  suspieiuu  llial  tlie  ca.-e  iiii^'lit  be  nm;  of  uiiihu- 
latory  Ivpliuid. 


Afebrile  Typhoid  Fever. — Altlidiigli  with  iiicrca^iiiir  kiiowlfdjje  of 
till'  iialiii-e  and  iaaiiife>tatioii^  ul'  lyjdiuid  (ever  .--oiiie  >vinptoiii-  n  liicji 
wore  earlier  eoii-idered  patlKP^nKniKniic  df  this  emiditidii  were  finiiid  iidt 
to  l)e  -o,  it  wa-  iievertlieh'ss  l.elieved — and  this  was  still  tiie  opinion  of 
(Jrie-sin;,r,.p  ;i|„l  \V\ni<l<'rlieh — tiial  tiiere  eould  be  no  tvphoid  fever 
without  elevation  of  teinperatnre.  'I"he  modern  eonee|)tions  of  the 
inteetious  diM'a>es,  however,  nm-l  of  iieci^itv  have  led  to  tiie  belief 
tliat  ty])lioid  H'ver  also  Mii<,r|it  l>e  whc.lly  or  ahiio-t  wholly  unattended 
with  elevation  of  teiii|)erainre.  Just  as  occurs  in  other  inteetiou.s  diseases, 
as,  t"or  instance,  -carlet  fever,  niea>les,  and  variola. 

Every  experience*!  physician — the  i'aniily  physician  more  fre((Uent)y 
than  the  hospital  phy-iciaii — will  I.e  able  to  recall  that  durinj,'  the 
endemic  prevalence  of  typlxiid  fever  tlnre  occurred  UTider  the  ,-anie 
roof,  and  amid  the  same  Lrenerai  conditions,  side  l)y  -ide  witli  well-char- 
acterized cases  of  tile  disease,  others  in  wliiiii  indivirhiais  surtered  for  a 
eonsiderabk'  time  with  marke<l  languor  and  malaise,  witli  lieadaclie  and 
vertij,ro,  inv;;ularity  in  the  action  of  the  bowels,  diarrhea,  or  obstinate 
oonstipution  witii  flatulence,  and  were  comi)eIled  to'remai.i  in  bed  and 
in  their  room,  and  recovered  but  slowly,  but  in  which,  durin;,r  the  entire 
attack,  there  was  no  fever.  In  some  of  these  patients  examination  fails 
to  disclose  any  sp.rial  or.iranic  chaiifre  throufrhoiit  the  entire  course  of 
the  disease.  Loss  of  w 'i-rht  of  from  M  to  10  |>ounds  in  the  course 
of  two  weeks,  however,  indicates  emphatically  that  some  serious  con- 
•  lition  must  have  bec-u  present.  One  cannot  relievo  himself  of  the 
impression  that  the  ])atient,  who,  in  marked  conti-ast  with  the  ne^nitive 
orjranic  chan^r(>s,  has  Ix'on  so  jrreatly  redu.'o.!  in  weiirht,  nuist  have  been 
under  the  intluence  of  s.une  infectious  process  whose  nature,  in  view  of 
the  coinci<lenee  with  pronounce.!  .ases  of  typhoid,  fever,  can  scarcelv  be 
•loubted.  In  otiier  cases  one  nee<l  not  mak.'  a  diairuosis  by  exclusion. 
There  may  l)e  present  bronchitic  symptoms,  meteorism,  ciianictoristic 
diarrhea,  is,)lated  n.s.vihe.  or,  wli.it  is  ,,,,(  rare  and  is  especially  imiMir- 
tant,  recent  cniaru'enient  of  the  spleen. 

Th..  fre,|ueney  of  su<h  .ifebrile  .•ases  is,  in  view  of  tlio  uncertaintv 
and  variability  ,,flh.ir-ympt..matolo-y,natui-;illy.!itli.>ull  of  .-stimation. 
I'roba!>ly  it  is  vaiiabh'  .luriiii:  dithivnt  .  pi.lenii.s.  Wh.'th.T  .a  .■.rtaiu 
ni-'e  or  sex  especially  pr.Klisposes  to  the  con.lition  is  not  kn.iwn  t..  me 
from  personal   experience,  an.!,  so  far  as  I   know,  the  .lUi'stion   lias  n.,t 


;i(» 


lyniniii  ii:vi:i: 


hern  (■iiii-idtTcil  li\  dtlici'  Wlilii-.  '\'\iv  iliUficiiliMtiuii  ol"  tlic  (■;!>(  -  in 
(|ii(-tii'ii  ti'iiiii  ,-ii|)ci'llci:illv  similar,  nt'clirilc  iiioi'lii<l  i-iiiiilitii'ii>  iKiitirii- 
larly  -iiii|ilc  i^a-lre-iiitc-liiial  i-alarrli.  will,  in  tlic  tiilnrc,  \>\  iiicaii~  of 
tlie  ( iriilii  r-W  idal  rcaclimi,  In-  rcinlcriil  iiihtc  r<rtaiii  than  lia>  liicri 
|Ki->il>lc  ill  the  |ia.-t.  I'l'dlialilv  ,  al>ii,  liacl(i-icilii;;ic  t  xaiiiinalinii  ,ii'  ijic 
1)1m(m|,  the  urine,  ami  tlic  -todU  will  1,  '  lu  iiicjI'c  dftiiiili'  rc-iilt-.  It 
wiiiild  iiatiirallv  lie  artilicial  Id  -ciiaralc  llic  alilirilc  ca-i-  ni'  ivjilmid 
("ever  iiitii  a  rii^idly  di-linct  uriin|i.  Thcv  jiradiialU  |ia—  over  iiilo  thoM' 
cax-  ill  wliicli,  duriiiix  a  Imi;;  at'tlii'ilc  ihui-m',  miK  iiKidnatc  clcxalidii 
of  t(in|nTatiirc  oiwiir- tciii;^i'arily  or  tin- day,-.  A  liln-ih'  t\  jilmid  fcvtT 
cci-laiidy  conn  ilinic-  il-  (■oiiliiiiiriil  of  ca-o  to  llic  aiiiliiilaloi-\-  form. 

Iran    jicr- dlyi;i\c    nn   >iali>li(al    ilala  w  illi  i-rtiri  iicr    to  the   afelirile 

f(jriii  of  ty|jliiii(l  fe\.-r.  aitlioUL^li  i  lia\e  Men  a  (  on.-idei-alile  nninlier  of  >ncli 
(•a.se.<.  Mo>t  valiialile  e(iiiliilinlio|i>.  liuuever,  lia\c  lieen  niaile  liv  I.ielier- 
niei.-ter,'  uIuj.  aLTeeinir  with  tlie  |iraititioiiei>  of  JSa.-le  as  to  (lia:;iiosis. 
oliserved  many  eases  of  afelirile  ty]ilioi(l  t'ever.  He  nfilol  in  IMiit,  in  addi- 
tion to  L'Oti  ea.-es  of  more  or  less  uell-(levelo|ieil  Ivjilioid  teVer.  L".*  of  telirilo 
anil  ]-'l!»  of  afelii-iU-  al"loniinal  ealarrli  :  in  l><7<'.  '_'(i  ea,-es  ot'  ti'lirile  ami  11 
eases  of  afelirile  a'-loniinal  <atarrli.  in  adililion  in  Itll  eaxs  of  maiked 
lyjihoid  li'ver.  T  .e  slalemeiil  ot'  Lieliernieister  i>  al^o  iiilire.-lim:  in  this 
eonneetion.  lliat  in  l)a^le  at  iha;  time  individnals  who  dieil  of  other  (li^ea^e.>J 
or  a.-»  u  resnlt  of  aeeideiit  freijnently  exhiliiled  after  death  the  nnex|icelcd 
eondition  of  sliidil  swcllini:  of  I'ever'?  jiatelus. 

An  inslriieli\e  ea>e  of  afelirile  lyphoid  fe\  er  niider  in\(il  servalinn  in 
which  a  |iost-niiirti 'n  examination  wa.-  made  may  he  re|iorted.  Jl  ocenrred 
in  a  laliorer.  eiLditeeii  yeais  old,  who  liad  liccii  in  the  hosjiilal  foi-  two  weeks 
on  acconnt  of  •■  intestinal  <-alarrh,"  and  w  lio-e  leni|ieraiure.  lahen  three  limes 
dailv.  was  fonml  to  he  coni|ilelely  normal,  with  the  ex<'e|ilion  of  one  eveii- 
iiiL'.  when.  afliT  a  visit  which  disinrhnl  him  eon.-ideralily.  it  ro>e  to  :;>.-_'  ( '. 
He  exhihiteil  al>o  no  opecial  local  .-ym|iloms.  Iie\\a>  only  rcinarkahlv 
lanirnid.  entirelv  wilhont  apjietile.  |irestrated.  and  was  nnwilliiiL:  to  !;■(  t  out 
of  lied.  On  the  iifteenth  day  of  the  disease.  (|nile  wilhont  )irovocalioii, 
without  elevnlion  of  tcmiieralnre.  sym|itonis  ot' mental  dislnrliance  a]i)ieared, 
with  hallucinations  and  delnsions  of  I'ear.  In  an  nnirnarded  moment  the 
patient  spranir  from  a  window,  and  died  instantly  in  conseipienec  of  fracture 
of  the  liase  ot'  the  skull.  The  autopsy  disclosed  a  recent  enhir^rcment  of 
the  spleen  of  moderate  clcL^rcc,  h\  peremia.  and  iirm  medullary  swellini:  <if 
I'ever's  patches  in  the  lower  portion  ot'  the  ileum,  almost  down  to  the  valve, 
and  upon  one  of  ihe-e  a  siiH  adherent  central  slouidi.  perhaps  half  an 
inch  in  diamcler.  This  ohscr\alion  wa-  made  ln-t'ore  the  disi'overv  ot'  the 
typ'  'ddiacillus.  Iiut  the  iliat:nosi>  may  neverthelos  he  considered  as  defi- 
luti  !v   estalilished. 

WInli'  a  nimdier  of  c-tsps  of  afelirile  tyjihoid  fcxcr  may,  liy  reason 
of  their  atvjiical  .and  tnild  course,  lie  included  aiuonir  tlie  tnild  and  the 
mildest  variety,  others,  fortunati-ly  tlie  t^'nai  miiioritv,  lielonfr  to  tlie 
.severe   form,  even    that    with   a    fiit.il    termination.      The   credit    is   diir 


'  Li.c.  nt..  :i.  .Villi.,  S.  171,  17."i. 


^^?7^^^:r^'^^' 


VAIUATInys  I\  SYMl'TOMS  AM)  ((iriisr.. 


an 


psjiociallv  to  StniKf'  and  Fnintzol  ■  tor  liaviiii;  diroctiMl  particular 
{'.ttcntioii  to  tliis  .-iihjci't.  .My  own  expLriences  ari'  ciilirely  in  accord 
witli  tlioso  of  tiif  observers  named.  I  can  confirm  tiie  statement  tiiat 
severe  fjital  cases  of  t\|)lioiil  lever  in  elderly,  decre]iit  ]>ersons,  or  in 
those  dehilitated  hv  overexertion,  aicolKilism,  or  clironi>  disease,  may 
l)e  entirelv  imattemled  with  fevei',  or  may  even  he  aec<itnpanied  liy  a 
suhnormal  ti'iniwralnre. 

SEVERE   AND   MODERATE   CASES    OF   ATYPICAL   COURSE   AND 
S  YMPTOMATOLOO  V. 

In  this  section  will  he  di-<-iis>i'd  the  essential  facts  with  rpjrard  to 
sucii  r.ises  of  tvplioid  fever  as  present  deviations  from  tiie  u^umI  synip- 
tomatolotrv  of  tlic  di-case  liy  i-ea-oTi  of  peculiarities  in  their  cour-e  in 
{general,  or  on  accoimt  of  tlie  predominant  ;■'',/,■  played  l>y  certain 
svstems  or  indixidnal  orjxans.  'I'iie  literature  of  ditVerent  jK'riods  and 
countries  exiiiiiits  the  irrcatest  variation  in  tiiis  coniKH'tion.  While 
in  earlier  times  especial  weitrht  was  attached  to  tiie  variable  treneral 
])ictnre  of  tvphoid  t'ever,  and  aeeoidinirly,  as  is  tliouiiiit  to-day,  the  dis- 
eaM>  was  liir  too  >chematically  ilivided  into  a  ma>s  of  ditVerent  lortns, 
modern  conce]>tious  keep  in  min<i  rather  tlie  di-tinetive  picdominance 
of  certain  orjranic  Ic-ioii--,  so  tiiat  tiie  French  literature  e^pl'^■ially  is 
thus   ricli   in   varieties  e>tai>li-he<l  on   this  basis. 

The  Varieties  with  Atypical  General  Characteristics. — 
These  inav  at  the  pre-ent  day  be  di-po~iMl  of  in  a  comparatively  small 
amount  of  s|>aee.  It  is  »eareeiv  worth  while  to  re|)eat  all  the  de-it.'-- 
natious  that  have  ari-en  and  lia\f  been  employed  in  the  proi:ress  of  time. 
Wc  have  pr('viou>lv  mentioneci  tiie  so-calleil  jxastric  and  the  mucous 
t'ever  (Furntr  iiiiiciii:-<i-  of  the  I'reucli),  and  have  |)ointe<l  out  that, 
aecordini:  to  tlu^  sujr^eslioii  of  ( irie-sinn^er,  iIk-m'  names  had  better  be 
wliollv  abandoned  at  the  i)re~eiit  ilay,  and  be  re|)laced  by  those  of  mild 
and  moderatelv  severe  Iy|>lioid  lever. 

Not  much  more  can  be  said  of  the  desiirnations  pastric-bilious  fever 
or  bilious  fever,  which  were  tormeily  fre(|uentlv  eonsidere<l  as  the  third 
variety  of  the  "abdominal  forms."  Knder  the-e  ilesiirnatioiis  were 
inchuletl  those  cjises  oi'  typhoid  fever  in  which,  usuallv  in  coniunction 
witli  a  modenitely  -evci-e  or  a  severe  course,  gastric  disturbances,  a 
bitter  taste,  with  a  heavilv  ef)ate<1  ton<rne,  obstinate  nausea,  and  tho 
vomitinix  of  bilious  fluid,  with  severe  ])ain  in  tli(>  epi<.iistriuni,  pre- 
dominafr-<l  from  tlie  beiriuninir.  Some  writers  m(iition(d  in  tlii-  cornuH'- 
tion   the   fre(pieut   association   of  jaundic(-.      These  eases   esjxH'ially,  on 

'  JS.rliii.  kliii.    K'Mr/,.,  18T1,  X.).  30.  '  Zcif.   f.  klin.  Me,/.,  Bd.  ii. 


1 


::m 


srj 


l\2 


TYriinm  I  i:\i:i: 


■r::«^- 


^!S, 


1?' 


U'it"' 


:ic<'.iU!it  nf  the  \V(!l-kn..wii  ^.M.-at  raiil>   ..f  jaiiiKlicc   in   ca^cs   i.f  ivi)lii,i,i 

»'cv<T,  aiv   to   Im'   vic\v<.l\villi   particular   c-aiv.      A  con-id. ralilr    i il,,.,- 

of  iliciii  arc  not  to  he  atirilaitcd  to  infection  witli  the  liaciiln>  of 
Klici-tli,  i.nt  iVoni  tlie  ctiol.  i(  -tandnoint  llicy  arc  father  to  i.e  u-roii|.c<l 
willi  otiicr  tnoihid  eomliiion-,  aiiion^-  which  -eptic  |(rnee>-e.-  and  Weil's 
disease  arc  proiialily  tiic  ino-t  inijiortant. 

Ivcfercni'c  i-  \ .  ly  frc(|iicntiy  made  in  earlier  writinc--  to  vcrsitile 
ncrvou-  fever  and  to  >iii|ii<l  iiersdii-  fever.  'I'he-e  wi're  loiiir  inidis- 
pntcd  as  special  varictio.  A^  a  inattir  of  fact,  <-asc-  arc  fre(|neiilly 
oli.-crved  in  which  the  -pccial  -yiiipl.iin-  indi<'ated  liy  tlic-e  iiatncs  >o 
predominate  that  the   name-  may  Ke  retained   as   short   and   appropriate. 

It  >hoiild  not,  however,  1 vcrlooke.l    that  the  ditfcrcnees   indicated  l.v 

tlu-e  name-  are  not  cs-ential,  Imt  rather  superficial,  and  in  larp'  part 
individual,  and  tiiat,  lie-ide~,  \W  tr,cat  divcrMty  of  mixed  and  tran- 
sitional forms  demoiistr:ile>  how  little  impoilance  e:m  ho  attached  to  any 
such  ^trict  systematic  ditl'creiitiation. 

The  ilc-iuiiatioii  versitile  nervon-  fever  is  apjdied  to  oases  in  which 
symptoms  of  nervous  excitement  predominate  at  the  heitrht  of  the 
disea.-e,  at  times  al-o  throiit,diont  the  entire  fchrilc  period:  (ireat  rest- 
le>siie>s,  with  marked  motor  and  -eii-ory  irritahilit v,  delirium  ai  -lear- 
liifT  early,  i).'r>i-.tiiii.'   itito   the   day,  with   vivid,  L'-enerallv  friirh  hi- 

sions  and  halliicitialion<,  even  cryiiiL:  and  >hoiititii:,  with  a  ,isia  it 
tendency  to  ^^ct  out  ot'  lied,  and  oeca.-ionally  attempts  at  tli^dit.  Tremor, 
fl(i<'titation.  and  siihsnltn-  tcndinimi.  even  convulsions,  in  children  and 
irritalile  a(hilts  complete  the  clinical  picture,  wliieli  is  most  alarming  to 
the  friend-. 

In  contradis(ln<'tion  to  this  condition,  the  eases  included  under  the 
desiu-nation  -tiipid  ncrvon>  fever  in>tiiy  that  name  liv  reason  of  the 
depression  whi<'li  <'haraeteri/e-  their  eoinse  and  svni]  toms.  I'^rom  the 
()nts(>t,  or  at  least  diirinj^the  fa.-titriiii.i,  the  ])atients  aie  irrcatlv  dojiresscd 
])liysieally  and  mentally,  dull,  unresponsive  to  Mimnlation,  and  without 
will-pow(>r.  Sleepless,  with  eye-  open  or  lialf-o|>en,  they  preserve  a 
relaxed  dorsal  dcciihitiis  in  lied,  with  a  constant  tendenev  to  slip  down- 
ward. Without  lieiiiiT  (iilircly  nncon<cioii<.  ot'lcn  l)ein<:  I'nt  slitrhtlv 
stuporoii--.  they  are  indiU'creiit  hoth  to  individnal>  and  to  events  L''<iinir 
on  ahoiit  tlieni.  '{"hey  a-k  for  neither  IoimI  nor  drink,  lint  swallow 
hadly  and  slowly  tliat  which  i»  olfcred  them.  <ir  permit  it  to  flow  ajxaiii 
from  the  month.  Not  itircly,  especially  in  yoiniir  women  with  a  iier- 
\'ciii<  predi  jiovitimi,  the  condition  of  stupor  hccome-  in.  reasin]  to  the 
ilevelo|)menl  of  symptom-  of  catalepsy,  I  have  more  than  once  lieen 
able  to  demon-trate  cataleptic   ri^'idity  with   plastic  iiexiliility   in   indi- 


VMUATKiSS   l.\  SYMI'T'iMS  .\.\l>   idinsE 


■.\\:\ 


viiliials  who  wi'ic  (uM-idi'i'tMl  hy  llicir  iittciKlant-  as  ciitiiplctclv  >tii|MM'- 
iiii-,  and  i'\(ii  ill  wlmm  tlu'  typhoid  li'Vcr  was  ihoiif,dit  to  he  coniplicatt'd 
l)y  ni('niiij:iti~. 

The  ilirm  of  stupid  iivrvoiis  livrr  just  outlined  is  ap|)ruxiinat(lv 
identical  with  tlie  variety  of  typhoid  lever  de~crilied  1)\-  the  l-'reiich 
and  I'ai^Iish  as  tiie  adynatuic  form  ;  while  tliey  eni|iloy  instead  of  versa- 
tile nervous  tever  the  e\pres-iou  ataxii'  or  irritativi'  typhoid  tiver.  It 
iias  heen  inentioni'<l  that  trau-itions  between  these  tiii'ins  inav  o<cur  and 
various  clinical  pictures  he  |)roduced.  The  French  literatuiv  jjives 
expn  --iun  to  this  with  its  ataxo-adynainic  variety,  in  which  the  svnip- 
touis  ot'  exciletuent  and  deprcs-ion  may  he  present  in  varyinjx  dejjrces 
siimiltalieou-ly  or  -uece~-ively.  The  ataxo-adynainic  variety  also 
reseiuhles  that  desi;xuali'd  the  hyperpyretic  \ariity,  which  is  cliarac- 
terized  hy  the  t'a<'t  that  after  the  disease  has  pursued  a  relativclv  sFiort 
ami  severe  course,  with  depre--ion  atid  irritative  syni|itonis  side  l)v  side, 
the  fever,  whicii  I'roin  tiie  liei.qnnintr  was  coTisideralile,  rapidlv  rises  to 
an  excessive  Iieiirht,  when  the  majority  of  ]>atierits  >uc<aKnli.  Ca.~es  of 
this  kind,  piirsuiny;  an  e-ju'cially  severe  cour-e,  closelv  roeiulile,  in  turn, 
the  clinieal  |)icture  ot'  the  fulminant  variety  |)reviously  deserihed. 

It  is  not  clear  what  crises  earlier  prominent  [  !i\sici:iiis  (Miirehison, 
Trousseau)  includeil  under  the  (lesii,rnation  of  the  inllamniatory  varietv. 
They  apjH'ar  thcrehy  to  aim  at  the  lescriijtion  less  ot' a  special  variation 
in  the  ireneral  course  rather  than  to  include  under  this  term  such  eases 
of  ty|)hoid  f.'ver  as  are  attemled,  e-peeially  at  the  liej^inninir,  with 
severe  fever,  a  tense,  full,  imnsiially  fre(|uent  ))ulse,  a  hot,  drv  skin,  an 
intensely  nHldened.  swolliii  face,  with  injection  of  the  conjunctiva',  a 
I)uniiTi<x  thirst,  and  irreat   dryne-s  ,,('  tlie  mouth,   tontruc,  and   lips. 

\\  hile  the  cousideraiiou  of  the  varieties  just  descrilied  was  intende<l 
to  make  clear  the  ditrereiices  hetween  the  past  and  the  present  methods 
of  classitication  of  the  ditVerent  Hirins  of  typhoid,  one  of  thcsi  varieties 
may  now  he  referred  to,  whicli  even  yet  appro])rii!telv  occupies  a  dis- 
tinct |)osition.  Th,  is  the  so-ealle<l  hemorrhagic  typhoid  fever 
(hemorrha<ric  ]mtrid  li'ver  of  'IVoiisseau),  tiiat  variety  that  is  so  strik- 
in<:ly  and  alarmiiif^ly  eh  iractcrizenl  hy  iK^morrhaues  in  all  possible  por- 
tiou~  of  the  body.  In  a  number  of  rare  cases  it  constitutes  a  form  of 
termination  ot"  the  fulminant  varietv,  while  in  other  cases  it  ntakes  its 
unpre--  upon  the  (lis(>a-e  at  the  heiirht,  or  mav  eveti  occur  in  the  later 
sta<:es  of  eases,  which  at  tir-t  e\hibite(|  an  entirely  typical  I'ourse,  or 
whieli  had  even  pursued  a  jirotracted  conr-i>  { Wairner.'  ( ierhardt -). 
This  ilanL''er(>us  tendency  may  be  (irst  maiiit'ested   durinj;  a  relajise.  and 

'  DfutKi-h.  Arch,  f    klhi.  Mai.,   lid    xxxii.,  \w.ii.  '  Zrit.  f.  klhi.  Med..   IM.  i. 


'» 


m 


.'.l  I 


TYriinii)  ii:n:i:. 


..-'•r'.n 


tlii-,  Ml  iar  ;i>  I  know,  was  lir-t  |)((iiiliil  out  liy  (icrlianlt  aii<l  iin-clf  (in 
llic  lia,-i^  lit"  |iii--,inal  cxiHi'ii  nee. 

Su.  h   ail   iii.-laiicc  lia,-  iMwurrcil  at  tlu'  .luliiis  Iliipkiiis  Iln-pital,  and  was 

rc|iorliil  Ivy  llaiiiliiir-L'ir.       In  I  lii.- casr  llif  In- rrliaL'-o  lir.-i  a|i|ifanvl  on  llic 

Iniirlofiilli  (lay  ot'  a  nla|i.T,  ilic  uriiriiial  allack  hasiiiLr  lucn  ot'  nioilcrali' 
scvcrily.  'riurc  was  (|iiil('  in-dfusi'  lilcfiliiit:  tVuni  the  l'Uiii.-,  ami  iiiiiiicnuis 
liclcrliia'  ami  a  tcu  lai'L'ii-  |iiiriiuric  <|iii|:-  wen-  xattcrcil  ovir  lln'  IkmIv. 
Niitw.ilistamlinL'  llii>  iMiiiiiilii'Mtiiiii.  the  |ialii'iit  iiiailr  a  i'niii|,lctc  rcrnvcrv. 

riic  lii--l  licniMi-rliaLTi  -  a[i])rar  In  lakr  |i!a(T  iivncralK'  troni  the  nn-c. 
Iniincdiatcly  tiicnat'tcr.  at  time-  ••iniuitai:r(in--l\-,  licinnrrliairo  orcur 
I'mni  llic  c|i>c(i|(iiT(l,  -|iiin;^y  j:inn-.  'I'hcii  Mclccliia'  ,i|>|i<ar  iinim  tlir 
.~kin  iiC  till'  trunk  ami  ilic  cxtrcnillir-,  -callritd  I'ltwccii  llic  rip-iula', 
wliirli  (!ria-i(inally  iln  nut  iMinnic  lurnun-liaLiic  <ir  iMcuiiir  nulv  -I'lLihtlv 
>ti.  In  <'-|'r<'ially  iiiallLniaiit  I'a-cs  |iriilliiiml  i'\ii-a\  a-ation-  (if  IiIikkI 
inlii  tlir  -iiliculaniiiii~  cnnncitivi'  ti~-nr.  ivcii  limcalli  tlic  -cal]),  niav 
iiccnr  I  !■'..  Warner).  A  (•(iii^iilcralilc  niiiiilM  r  <<i'  tln-c  [laliciit,--  arc, 
lic~iili'-,  -ii/c(l  with  nifnini^ial  ami  (■ci'iiirai  Ik  imirrlia^c.  V.M'U  nidrc 
l'i'r(|nriilly,  iiidciil  in  the  uvrrwlichniiiir  inajurity  ot'  all  ivix-,  inlc-tinal 
linmuiliap'  urciir- :  at  linir-  iirinLT  in  sucli  aliniidam-t'  ami  dccnrrinj,' 
willi  .-mil  tVf(|iicnl  npctitiiiM  ilial  it  may  lie  ruii-id.  ivd  tlic  <liiTct  can-c 
<il'  licatli.  in  line  ca-r,  w  liich  tri'iiiinatril  tatalK'  a-  lai-lv  a-  tlic  .-i\tli 
day,  in  tlic  cdinv-c  nt'  a  |iriifii-c  licinnrrliaiic  tVinii  tlic  liiiwcl.   |   tliiind,  a.~ 

tlic   anat ic  ha-is    tin-  the  lallcr,  that   tlii'  IN  \c!'"s  |iatclic-.    in    the  lower 

jioriinn  of  the  ileum  were  e\<'ccdiiiLrly  .-]miii;^\-,  friahlc,  and  infiltrated 
\\illi    reddi-h-lilack    M I. 

.Not  i|iiiie  -o  I'oiiinion  a~  tli"  form-  of  heiiiorrliai:'e  iiicntioued  i>  that 
from  the  urinai'y  tract  and  the  genitalia.  I'rei;naut  women  Mi/e<l  with 
the  licmorrhaiiie  \ariely  ot'  ty|ilioid  t'e\cr  iii\arialil\-  almrt,  and  then  di<'  as 
a  r<v-ult  ot'  uiicoutrollalilc  uterine  lieiiiorrhai.''c.  Heiiio[)t\>i-  aiiiicar-  to 
lie  the  lea-t  cou-tant  tiirm  ol'  licmorrhaLic.  and  when  it  occur-,  it  mav 
lie  attriiiiited  ciihi  r  to  iutiirciion  or  -inijily  to  lilccdiii:.r  t'nmi  the  liroii- 
ehial,  tracheal,  ami  laryn^'eal  mucous  incniliraiic.  ]n  the  further  course 
of  the  (li-ca>i'  uanureiKiu-  |irocesscs  may  lie  added  to  the  iiemorrhairc-  : 
[  Iccratixe  de-triictioii  of  the  u'lun-  and  other  ]iarts  ot"  the  liuccal  mucous 
memlniiiie,  |)ulmoiiary  ^aiiLi-rciic,  L'^encrally,  it  is  true,  in  coiijnncliou  w  ith 
infarction,  and  |iseudodi]ihthcric  lcsi(in>  of  the  uterine  and  ve.-ieal  mucous 
incmliniuc. 

With  rcL'^ard  to  the  nature  and  the  mode  of  oriuiu  of  this  extremely 
malitruaiit  \ariel\,  which  is  fortunately  rare,  iiolhiiii:  i>  as  vet  known. 
If  the  modern  clinician  -neer-  at  the  c\|ires-ioii  '•dissolution  of  the 
lilood,"  ein]i|oyc<|  l,y  hi-  ]ire<leccs-ors.  he  -iioidd  licar  in  mind  that  he 
lias    not    a-    yet    provided    a    lietter   >uli-titute.      .\t    ]irescnt    we   do    not 


VAniATIn.XS  l.\  SYMriOMS  AM)  (  nllisi:. 


316 


know  whrtlitT  ^|H■(■i:ll  clianH'tcri-tir,-  and  in(Hlc  uf  ailicm  nt'  tlic  t\|)liiii<l- 
hai'illii-  (ir  wlictlicr  cfiMain  i-iinditinT]-  nf  tlic  I>imI_v  or  the  ctllci-  nt' 
certain  cdniiilicatiiin-  |ilav  tlic  riKi-t  ini|Kirtant  ri'ih  in  tlii.-  (•(iniicclion. 
Kaiiicr  writirs  (  I'mn-scau)  claiinc*!  to  have  c-taMi-hiMl  tliat  in  tlii' 
cMM'-  in  (|ii(-tioii  tlici'c  occnricd  a  -|H(iai  alteration  in  tlie  li'  •kI,  ehar- 
aeteri/ed  liv  a  retnarkalily  dark  color  and  di'ticient  eoaL^nhi  .ility.  1 
lia\'e  i«'r--onail\,  in  tlie  exaniinatioii  of  one  ca-e  durinjr  lile,  not  liceii 
alile  to  denion>trate  eitliei-  tlic~c  rnaero-.eo|iie  |)ecnliarities  or  note\\oi-tli\ 
lii^tolo;jic  (•lian;.''es  in  tlie  Mood.  In  the  ca>e  aliove  inentiiini<l  a-  occnr- 
y\\\<1  at  the  .lolni>  Ilo|)kin~  llo-])ilal,  howesci'.  llie  eoai;ldation-linie  ot' 
the  IiIihhI,  dunnu'  the  period-  when  lieMiorrha;ie-  \\ere  occurring,  \\a> 
increased  to  ten  niinntes,  Iml  dnrinir  com  ale-cenee  it  ajraiii  Kecanie 
rednced  to  t'onr  niiinil  -.  It  slionid  e-|M-eidl\'  he  eni|iha>i/t'd,  liouivcr, 
that  neither  in  any  ot' my  ca>e-  nor,  -o  far  a-  I  can  learn,  in  the  li'era- 
tnrc,  has   henio;:ioliineiiiia  with  hcnioMliiliiniiria  lircn  oh-eived.      (aret'id 

examination    of   tlu'    M l-ve--el-,    partieularlv    the    ca|iillari( -,    which 

]io--il)ly  may  -how  alteration-  of  mcire  iin]iorlanec  than  ehani;c-  in  the 
lilood  it-elt',  lias  Vet  to  lie  made. 

With  rcixard  to  the  i;'eneral  eiio|oL;ic  condition-  in  the  cases  in  ipies- 
tion,  childhood,  .is  well  as  vonth  and  adole-i'ence,  a|i|iears  to  lie  more 
)ire<lis|)o-ed  than  the  later  [icriods  ot'  lil'e.  ( )|'  il  ea-e-  nnder  mv  own 
ohservation,  -'i  ipi'enrreil  in  chiMhiod.  'I'he  olde-t  ot'  inv  patient-  was 
thirty -six  years  ot"  aL'c.  \\'aL,nii  r  and  (ierliardt  al-o  emplia-i/e  the  pre- 
di-position  exhiliitcd  hy  children.  'i"he  con-titntioii  and  the  mode  ot'  lil'e 
apparently  do  not  ])lay  the  rnlc  that  niij,dit  n  jirhiri  Ix'  attrihntet '  to 
them,  (icrhardt  and  ( u-ic-sinLrer  inelndc  -corhntic  states,  delieient  nonr- 
ishnient,  and  livintr  in  o\  ercrowdeil  rooms  anonc;  the  contrilmtorv 
causes.  In  my  cases,  however,  notliinj:  ot"  this  chanictcr  appeared  in 
the  histories.  Of  j^reat  importance,  li(,wcver,  apjiears  to  me  to  he 
](revioUs  alcoholic  cxee-s.  Of  niy  .'i  adult  patients,  2  were  notorious 
drunkards. 

With  refritrd  to  the  fre<ine!ioy  of  occurrcnco  of  tlic  lienmrrliaL'-ic 
variety,  it  may  lie  re|)c,itcd  that  T  liavc  [MTsonallv  observed  oidv  •! 
definite  cases.  Liehcrnicistcr  notc<l  Init  ."5  amonj:  \'M)()  cases  of  tvphoid 
fever  in  the  epidemic  at  Ilaslc  ;  and  AVeil  lint  1  amoiiir  lo<>.  Anionir 
S-2!t  cases  at  the  Johns  Hopkins  Hospital,  only  1  case,  that  above  nien- 
tioTied.  oicnrred  Slijrhtly  niarkinl,  mild  liemorrhairic  cases,  however, 
appear  to  he  not  nt  nil  rar.',  T1im<,  in  jiersoiw  irreatly  exliansti'.l  in  the 
.se(pience  of  protrncte<l,  severe  attacks  of  ty])hoid  fever,  or  in  tho-e  with 
sjH'cial  predispositii.n,  as  in  .nhnormnlly  ohcse  individuals,  women  and 
children,  and  csi)e<'iallv  in  hecr-drinkers.  tlwre  is  m.t  i~ir,.lv  i,l.-<.rv..,l   tt 


1  ^_  I 

r 


.tlli 


TYrilnll,    IIAI.U. 


■A  latr  -t;.-r  of  ll,,'  ,li-,':l-,  ;l  lllalkr,!  t.-,„|rll,.\  lo  li,.nior|-||i,L:c  fruiu  tlir 
Mm-,  ,     ill.,     irlllll-,     lllc    colli, ■!•-     ,.r     ||„.     I nil.     a,,,!     |i--||r,-     ,,t'     lllc     li|„. 

Su,l,  in.ii\i,|ii;il-   ,.vl,il,il    a    1,11,1,  ii,.\   t,,  ,Al.ii-iv,-    li, rrli.i-,  -   ini,,  tli,. 

>kiii.  ill,.  Mil„iil:iii,-,,i|,  ,-.,iiii,-,-li\,.  li-ii,.,  :iii,|  ,A,.||  iiii,,  t|„.  mil-,. I,.-,  ;„  ;, 
r,.-nlt  ,.r  til,.   -.JiMl,,,.-!  traiMii.ili,.  iiillmii,., 1„.|,  ;,,  ,1,,.  |„.,.„||,v  .,f  ,1„. 

'""'-'■'-  ''■""'  ill  iiiMvin-  Iii,n,,.r  ,,r  ili,.  |,i,.-ii,,.  ,,|-  ,irli,l,.-  ,,|-  ,.|,,iliiiiir 
or  <<t'  ill,.  -Ii,,.|. 

'I'lir  im.-ii,.-!-    ill    III,.  u,.||-Mi:irk.,l  li,..ii,,rrli:ii:i.'  varii.fv    i-  ii,   >."M,.ral 

tl„.  MMMv  uni;i\,,ral,l,.  Ill,,   larli,!-  lli,.  li,.,ii,,r,.|uo,.-   a|,|„.ar':i,i,|    ,||,.   , .,, 

.■\I,ii-iv,.  tli,.y  aiv.  All  inv  C  ,•;,-,.-.  I,  riniiul,.!  talally.  \\a<:,uv  1,,-| 
l>ut  lu,,-tlnnl-.  ,,(•  hi-  ,,a,i,.,i,-,  Tl,,  |„.,,^.,„,.i,  j,,  ,|„.'  .li„,|„l_,.  ,„arkiKl 
ca-,.-   ,l,.|M.|i,|-    ii|>.,ii    til,.   ,,tli,.,.   a— ,M-ial,.,l   cnhlitidii-. 


I 


1 

^1- 

5ff 

TYPHOID  FEVER  IN  WHICH  SYMPTOMS  REFERABLE  TO  CERTAIN 
ORGANS  OR  SYSTEMS  PREDOMINATE. 

'■''"■  "i.U"i-il.v  of  III,.  ,•:,-,.<  t,,  |„.  ,.,,ii-i,l,.r..l  ill  tin-  .-,.,.ti,,n  tiave 
already  l,....ii  ivtrrn,!  t,,  in  ,.,,iiii,.,.ti,in  ujih  ,1„.  analy-i-  ,,r  th,.  IikII- 
vi,lual  -yni|it,.Mi-.  It  uil|  |„.  i,-,.f,|l,  li,,w,.v,.f,  |,aniciilaily  uitii  v,.sw\ 
to  tl„.  .iiairiio-i-,  I,,  n.vi.u  ill,.,,,  clinical- pictiin-.  aii.l  t..  ".■,iiiii,|,.t,.  tlic 
detail, ,1   <l,.-cii|plioii. 

Typhoid  Fever  in  which  Symptoms  Referable  to  the 
Central  Nervous  System  Predominate.— ( ^nhral, -pinal,  and 

crivlii-o-iiiiial  varicii,-  may  1,,.  ,li-tin.irui-linl.  Tl,,.-,.  hav,.  pivvioti-ly 
Inrii  fully  c,iii-i,lciv,l.  >,,  tliat  at  tin-  |ilac(.  it  uill  Mitfi,-,.  t,.  rder  ajrain 
oidy  to  il„.  ,.ascs  that  -,.t  in  with  -,.v,.i-,.  <.,.r,.|if,,-|,inai  >ym|itoni,-  aiufarc 
(■V(.n  chafa,'t,Ti/,.,l  l.y  a  |ii-(.<lnminanc,.  of  th,-..  ( rnciiini.n,ty|)li,,id),  and 
t,i  th,,-,.  in  wlii,.h  a  c.miili.x  ..f -..v,.|v  spinal  >ym|it,,ni>  iv-.inhlinjr  :,(.ntc 
(Landi-y^)  a-(vn,linjr  |,ai-aly-i<  ,.l)M.|ir(.  the  piitniv  of  ty|,|i,,i,j  fever 
wli,illy    l)ey,)n,l    recpj^iiitioii    (  Leiidet,   ( 'iirseliliiaiin  ). 

<H  the  -.-,.all,Ml  ,.,'rehral  variety,  oidy  those  cases  will  ajraiii  he 
refeiT.'.l  to  tnat  ar<'  ,|nite  early  a-soeiat,.]  with  -eveiv  mental  .li.-tnrl.- 
nnee<.  The  irreatest  ,liairn,,>ti,.  ditli.ulty  may  attend  tho-e  eases, 
whiih  ai-e  i-are,  it  i-  true,  in  which  the  atta.'k  of  typluml  t;.v,.r  >et>  in 
with  the  >ymi.tom>  of  a  psychosis  a, id  the  <-haraet,.ri-ti.'  inanii;.-tati,,iis 
of  th..  iin.l..rlyiii^r  ,li-,.as<.— the  ros(.oke,  .•iilarf:..ni.jit   .if  tlu^  spl,.en,  and 

diarrli.a— .1 i   app.ar  f.r  day-  an.l  evn  f..r  a  w....k  after  th..  .in-..t. 

It  i-  a  niatt.'r  ,.f  ..xp.Klii.n.^y  r.i  >p(.city  .-n..h  ca-^es  with  th.^  d.-i^rnatiou 
eer.'hral   typhoi.l. 

Anionir  the  disorders  of  the  respiratory  organs  that  at  times 
pv,.  an  miu-ual  eliarneter  t.i  the  e.mrse  .,f  typh.ii.l  f..ver,  those  of  the 
larynx,  the  hinjrs  and  the  pleuni  are  the  most  iiiiiiorfa.it      Ar,„.T„T  tl„.<„ 


f  I 


r.i/:/.i //ov.s  i.\  M  .i//"/'oi/s  .i.\/'  (nri:si:.  :!17 

tlioM' (it"  tlic  larynx  arc  tlic  nin-t  ami  llic  lia-t  cMi-piciioii-.  < 'a.-f-  in 
wliicli  llic  entire  rlinii-al  pii'lnri'  i~  durninatcd  liy  the  carl^  (Hi-et  aii<l 
iinil-ilal  (livil(.]ini(nt  nt'  the  ty|(lii)iil  li'.-ii.n-  i>\'  the  larvnx  ;ire  exireniely 
rare,  and  the  de-ii,'natii)n  larvn'^otyiilmid  i>  artitieial  and  >ii|Mrtlii(iii,-. 

( )t'  tar  inure  >ijrnilieaiiee  are  tl^'  ti^rni-  i,i('iiiiiotiijiliiii(l  ancl  ji/ihi-d- 
liilili"i'l.  Vi'V  the  jil-litiealion  ,,{  the  ile-iL^nation  |)nenniiity jihuid  ( ior- 
liardt,  I'otain,  I,e|(iiie,  !"..  W  a^Mier,  and  recently  Kmrert  '  have  tiirni-he<l 
ahnndant  evidemi'.  Tlii- eondilion  i>  (il)>erv<  <!  in  tho>e  ea-e- i>l'  typhnid 
fever  in  which  -yin|itipni-  of  |inenniiinia  a|i|Mar  diirini:  the  tir-t  day-. 
so  that  the  tir-t  week  is  either  dominated  entirely  liy  a  tyjiical  clinical 
picture  of  intlanmiatioii  of  the  iunir.  ""'  the  latter  i>  attende<l  with  other 
syiiiptoins  iiiui-ual  to  it,  Imt  which  are  tor  a  time  of  nndeierinine<l 
siirniticaiH-e.  Such  ea-e-  nia\-,  a>  has  lieen  |Hiinted  ont,  lie  wholly 
iiiir(roi:ni/ed  at  tir-t,  ami  i>e  correctly  interpreted  only  toward  the  end 
of  the  lir-t  or  even  in  the  l)e;;inninir  of  the  -ccund  wti'k  of  the  disea>e, 
when  the  pnennionic  -yniptom^  recede  and  tho-e  eliarael<'ri>lit- of  typhoid 

fever  ( le   more   into   the   tore^'rciund.      I 'ndoul)te<lly,  the   majority    of 

such  easts  are  to  ho  eon^ider(•d  as  due  to  a  mixed  infection,  .\moiij; 
the  associated  or).'anisms,  pmhably  the  iliploeoccus  of  l-'niukel-W  eieh-el- 
bauin  occur-  the  mo-t  t'rciiuently.  The  ca-es  arc  likely,  jii-t  a-  tho>c 
of  ^cmiine  tihrinou-  pneumonia,  to  hesriu  with  a  chill,  with  -ul»ei|Uent 
marked  olevatiou  of  temperature,  au(l  to  he  followed  liy  the  rapid 
development  of  dense  loliar,  ireuerally  nnilateril,  intiltratiou  of  the 
lun<rs,  ofteti  with  characteristic  rusty  s|)utum.  It  is  jK)--il)le.  however, 
that  the  typhoid-hacillus  may  also  iu<le|M'udeutly  cau-e  intl.immiltury 
alterations  in  the  hm^s  (as  claimetl  liy  I/'pine,  ( 'hautemesse  and  \\  idal), 
and  such  cases  would,  as  has  hiH'U  [Miinted  out,  he  examples  of  jineu- 
motvplioid  in  the  striete-t  sense  of  the  term.  l'"urther  work  is  ni'<'<le<I, 
however,  hefore  it  can  he  cousidereil  as  cstahlished  that  such  cases  ever 
occur  (Vee  paye  llti).  It  has  heen  elaimetl  that  such  ease-  are  charac- 
terized liy  frequent  aliseuce  of  the  initial  chill,  hy  delaye<l  involution 
and  ahseiK'c  of  the  char-acteristic  rusty  s|)utum,  and  iiy  less  rapid 
ascent  of  the  temperature-curve  and  less  dense  intiltnition  of  the  lini^ 
than  occurs  in  the  eases  due  to  the  pneumococcus.  It  is  maintainfHl  by 
some  that  in  such  oases  the  'testinal  sym|)toms  are  frtHiuontly  lint 
slig-htlv  marked,  if  at  all,  and  the  devolo|)meut  of  msetilfp  is  altoirethor 
w  intinu:.  Our  exju'ricnoes  "n  this  connection  apjiear  t<i  me  to  he  too 
small   as  yet  to  justify   such   i^enoral   statements. 

Ah  an  instance  of  ]inenniotvpli()i(l  I  niav  <'ite  the  ease  of  a  man.  twenty- 
eight  veurs  old,  in  wluim  a  moderate   irrade  of  intiltrati<in  of  the  lower  lol)e 


.•;i.s 


I  )  riiniii  1 1  \  I  i: 


I 


nt'llic   IctI    hlM-.  ;is-.i,  lal.-l   uilli   rlilllii,,-..  Mll.l   il  >l.|  i- 1 1  kr  .i.^N  111  i.,ll  nf  t.ril  |..T- 

•'l>i'«'-    un-.'.l.       A"..,  i:ii,.,|    uilli    ihi-    ih,  IT    u,.,-,.    rnaikr.i    ilrvii.-.-.   ,,|    il,,. 

'""-'"■•  I'alpalilr  crilar.riiHiil  ..I  llii  ■.|,|,rii.  iiii.l  >li_'li|  mi.  l.nriMn,  ImiI  iki 
'lianlirM  ,.|-  n.M'.,hr.       Ai  ihr  ,  n.l  ..i'  ||„    ||,,nl  wc.k  ..l    i|,r  ,li,,-ii.-.'.  :ili.r   ili,- 

l'l"'l' 'i''    l-'illHili.lMlioii     liM.I    rM-l,-.|    r.,|-    iHo   «,<k.-.    llll'     I.  Ill|i.ni|l||-c    lill    In 

'""■'"•'I-      >iMiTri    .|;i\>    lain-    lliii'c    i|.\  .I..!,,  ,|    ili,-    >mii|.I -    ,,f   n    U|,|i,,j,| 

nlM|.-r,  uiili  a  cliai-ailiriMir  lil.rii.-  ...ur-.-  ..1'  llnv,'  uc.  k-,  uiih  nii.u,,| 
fiilarLrciiiriil  ..I  ill,  ,-|,|.rii,  i..|,|,M|v  ainl  rii.|iaiil  |.ca  >i.U|.-likr  -i,,,,!-.  alula 
\\rll..|,\,'|.i|,c.|  i-..,-(  ..|nu>  .  \aiilli<iii  Mil  ill..  iiiJiik  aii.l  ill.-  ii|,|.,  r  |H.rti..ii>  ,,f 
llll-   lAin  iiiiiii .-.. 

I  II.'  .■..111--.-  ,,|'  |.ii.iiiii..|\  |ili..i.|   a|i|M  ar-  |,,  1,.-  in  ;^,  m-ral  ih.i   -, ,  -,  \,.|v 
a-  u..nM    ,<    y.,;.„;  I,.- ,A|...i..|.      (..ihaiiji    vav\\    .iiiiilia-i/i.l    ihi-.       |i. 

'" I    ii'.\    '■■■i-''~   il.aili  ...■.nriv.l   li'.nn    |)iiliii.iiiaiy   i^aii-niir.      'I'lii-  .a-c 

"■'■■   II"'    i'.\:iiiiiii..l    l.ai'i,  ri..|..L;i.-all\.       In    aii..|li.  r.  .In,'    i.,  ili,.    |''rank.'|. 
W  .i.-li-i'lliaiilii    ili|il......vu-,    .iiipv.  ma    .1.  \ ,  |..|,..l,    l.iit    ihr    ra-i      Ciiallv 

"I'liiiii'i'''!  ill  iv.'.iv.rv.  .\llli..ii-li  ill,'  Naii.ty  kii..uii  a-  |.iiiniii,i- 
'M'li"'''  i-.  "II  'li''  ^^li"l.'.  raiv,  it  .I.M'-.  II. A.. rill,. 1,.--.  al  .-..in,'  liin,'  an, I 
.liiniii:  .filaiii  ,pi,|,iiii,-~  a|i|Mar  |..  Im'  iii..iv  riv.|ii..|il  I  <  i.ilianji.  |-:. 
^^■i-l"l'l-  '  I'.i^'  |i.T-'iiaMy  ..l,vT\.'.l  -J  ca-.,-  ,if  |,ii,iiiiH,I\|,li.ii,|  at 
'•"■I'i'i  'iii'l  I  :i'  llaiiiliiii-  at  liiii.-  uImii  ir.iiiiiiif  lilM-iii.iii,>  |iiiciiiii..iii:i 
|iii\  ail.'.l. 

Pleurotyphoid.— .Iii-i  a-  ,lmin-  tli.'  ...iir-,.  ,,r  upli.,i,l  fi  v,t. 
|il,  iiii-_\  ...•.iir-  iiiii.'li  1.^-  riv.|ii,'iill\  ilian  |iiiiaiiiii.ina,  -.>  aU.,  ,1,.,-  \\h- 
,~Mii|,n.iii-,,.iii|,l,A  ilial  iiia_\  I.,' ,|,-i^r|iat,-,l  |.l,iinii_\  |,li.  ii,|  apjicar  l..  he 
-nil  1,"  frc,|ii.'iii  iliaii  iiii,iiiii..t\  |ili,,i.l.  N,'\irili,'l,  — ,  lApiTi,  mv.l 
.liiiKiaii--   will    lie   alii,'    I,,    r.ralj    ca-,-    in    « lii,-li    -viii|.t,.iii-   ,,('  |,1,  iiri-v 

il,v.l,,|i,'.|.  o..n,. rally  a-.uaal,',!    with  ,liilliii,>,  and  .Milw,',|iii'nt ,w  ,if 

li'--  mark,',!,  riiniiti'iit  ciiiliiiiicii  W-wv.  Tlio,'  ,'M-f~  ware  tliin  at  tir-t 
ciii-iil.Tci  a-  ..f  in.|.|icii(|.'iit,  >.i-call<'<l  rln'iiinati.',  .ir  ..f  ..tli.r  iti,,!.,^],. 
<>rii:iii,  iiMlil  li,.a,laclif,  iir,.i;iv.— ivc  >tii]Mir,  .■nlari:,in,iit  ,.('  tin-  -|il,.cn, 
cliarrhia,  an. I  in.'t.'..ri-in.  a-  w.ll  a-  n.-,cla'.  .-.tal.ji-lii-,!  ih,-  ixi-t.'Mc'  ..f 
an  atla.-k  ,.|'  ty|,li,,i,|  tivir  |ir<-,ntinL'^  it-.ll'  in  tin-  |,f,ailiai'  aii.l  i-aiv 
niann.'i'. 

I  liavi-  i)(ts,iiim1Iv  .iI.m'i-vcI  4  .'asf.-.  nf  tliis  .-liarailcr.  In  ?,  oo|,i.iii3 
(■t;ii>i..ii~  ,|,'v.'l..|..',l  ra|.i.ll\.  Iicini:  in  l' ,,t'  a  |,ur.l\  >.n,iis  i-liarait,r.  while 
in  1  II  ua>  MT.Iii'iiK.rrhaL'i".  Thi-  f.iiirth  va>v  \\a>  unaltcii.lf.l  willi  ctrii- 
'■'"II-  ■'  >li:>ll  hi-ictly  >k.-I(h  thi-  la>l  .a.v  an. I  ..ii.-  ..1'  ih.-  i-mm-s  with  i-ll'iii-i.iii. 
I  saw  the  ca.-.' with.iiit  cti'iisiiiii  in  thcy.-ar  1  >;'<•;.  .Iiiriiii:  ilu- l\  |ihi,i,|  .-i.i.h-ini.- 
in  HaiiilinrL'.  It  .icciirrc.l  in  an  a>s,->s..r.  thirty-nnc  vcai>'.,hl,  «li,,.  alii-r 
haviiiL'  |ir.-vi.iusly  hecii  entirely  well,  wa.>  >.i/,.-,l  .'liiriiiL:  a  .-.■-.-iim  with  i-liilij. 
Iiesi-  aii.l  .-.-ver.-  |,ain  in  tlic  riL'ht  >i,l.-.  Tw,,  ,lavs  lalir  tli.-  |.a;i,-M  -h.jwe.i. 
Ill  a.l.liti..n  to  the  >vniiit..in>  .if  sli'.'ht  .litl'iiM-  l.i-.in.-liiti>.  e\ii-n>iv.-  i.leiiritic 
f'n.-li.,n  ..v.-r  tli,.  |.,w.-r  h.h,-  ,,f  the  ri-lit  liiii-  In  vi.w  ,,f  th,-  iiiiMJerale 
el.-vati.in  .if  teiii|i.-ratnr,',  th,-  .ic-,-urnii,-,-  ,if  .-.iiiMih-ralili-  <tii|i..r.  ilryiiess  of 
the  toiiLrtie,  an.l  a  lar-'-.  lialpahle   snh-iiii-  tiini.ir  was  .-trikiier       ( ),,  'tl„.  iiol, 


ii/,7r/V"\^  i\   s)\iri"U^    i\/'  (iiii:^r. 


.'.19 


<iM\  r.il|i>uinL'  '-<-\ciitli  iliiy  u|'  \\iv  .|i-c:i-i' ■  .|i-liiir|  rn-c,!.!  niu'li'  llicir 
aii|n'ar;iiiri-  ii|>nri  llic  mIi  iiiiiicii,  <-lif^l.  iiinl  li:i' k.  <  mh-i.I.  nn^'  llic  Iciii|Mr- 
alurrciiiir-'   mimI   tin-   iinminiiiL'  >\  mi|'I"1ii-.  llhrr  »ii-   iio\v   im  furllirr  dnulil 

tliMI    ll :iM-  «:i-   Mill'  ..f  t\  |i|ii,i.|    Irv  IT  u  liii-r    lir.-l    iniirki'l    .-Mn|il -ui-rr 

rc-liT;ililf    [i<    till'    iilufM.       Till ur.-i'   nf  ihf    allMi-k    u;i-   r.i\  muiilr.       I'Ih' 

|iMlii  III    u;i-     ll-ir    iVolll    IrMT     MHiI'    llir    lil|iM'  nl'    |nlir   Urik^.    Mini     In-    Ti  T' .\  i  ri' I 

r;i|iiillv  aii'l  i''iiii|ilct(l\ .  'llic  |ilriirilii'  frii'limi  |m  i-i-inl  imiil  ilir  riL'liili 
I  lav  i.r  I  III'  ilivM-r.  Si-ii^  i.r  Milli.-i'iii  I'l'  I  111-  ;illi''ii  1 1  |Hirlioiis  nl'  tin-  pliMira 
NMTr  iilwlil  :il  :in  t\iitiiiii:ilinii  iiiM'Ii-  :i   li:ilt'-\  t;ir  l:ili  r. 

riir  nllirr  I'iisi iMTTi-'l   ill  a  nun  liaiil,  Iwnilv   -cmm  \c':ii>  hM.   ulm  ua.i 

inlinillcil  Im  the  el  i  nil'  nil  llic  lil'lli  ikiy  nf  llir  ili-iasc,  ainl  nhitiil  I  hat  inii::h, 
u  illi  |iain  ill  liic  side  a  I  111  a  ililliiiiln  in  lirralliinir,  liail  ln-cii  llic  lir.-l  -\  iii|)- 
Imiis  ,,l'  llic  allack.  <  »ii  ailnii--i"ii.  a  la,_'c  riirlil  -i'lcil  M-riilicninn'lia'j'ic 
|iliural  1  irii-iiin  \\a-  ili-c,,\  rrd.  I' lie  h  fl  Iuiil'  «a.-  iiilaci,  uiih  llic  c\cc|iiinii 
111'  a  \\\\   lirnnclniic  r.ilo.      'I  In    -|.|iiii  ua>  iml    cnlar-cil,  iih  Icri-m  wa-  iini 

|irc.-ciil.   an. I    llicn-   ucic   im    rn-cnkc      'I'lii Iv     rcinarkalilc   t'taliiri    \\<\-  a 

ra^r  111'  -ini|ilc  M-ri  iii>  |>li  iiri^v  «  a-  llic  iiiiii^iial  lciii|i.  raturc-cniir-c,  u  liich  was 
thai  n|'  a  coiiliiiiicl  liAir  n|'  iiimlcralc  ilcu'i-cc,  uilli  lull  -li^lil  ilaily  lliict- 
iialinii-.  Nni  ijiilil  llic  ci-lilli  .lay  ili.l  chararlcri-tic  |.ca-i.ii|i-Lkc  -luiils 
a|i|icar.  At  tin-  -aiiic  time  ciilai'L'cinciil  i.l'llic  .-|ilccn  cmlil  lie  ilcinnn.-lralcil, 
liiit    ru-ci.hc   I'ailcl    In    a|i|icai-   cither  at    ihi-   time    or   >iil)!*ci|iiciil  ly   iliiriiiL: 

ih iiifsc   nf  the   ili>caM'.      (  111  I'  >ii.-|iiciiiii  that  llic   ca.-e  ua>   one   n\'  |ilcuri>- 

lv|ihiiiil  was  ciinliriiicil  l.v  the  |.ii-itivc'  foiills  yiciiicij  hy  the  (  iriilpcr-\\'iilal 
a;^L'liiliiialii)n-li  St.  The  case  Icrniinalcil  in  reeuvcry  at'lcr  a  iiiosi  priitraelcil 
(■nurse.  Till' cirusinii.  which  had  In  l.e  i-vaciiatcil  liy  tlinraciH'ciitcsi.s  on  the 
luciitv-cii:hlh  ilav.  did  iml  rcaceiiiniilatc. 


M\'    uwil    ea-es    Were.   1  III  |i  ill  I  lll.llcly  .   llnl     e\alllillcil     I  i.li'tcrii  ih  iLMcailv. 

It  is  ccftaiii,  hiiwcMf,  llial  llic  t\  |iliniil-liaeillii-  ahuie  may  cait-c  jilcii- 
ri»v.'  'I'lic  case-  ill  wliicli  tlii~  lias  liccti  ilciiinti-tniltfl  riillil  llic  most 
fiLTiirnii-  rcijiiifctiictits  tliat  cniiiil  lie  ilciiiatnleil  I'lif  tlic  cstaMislimeiit  of 
|ilciifiiiy|)liiiiil  as  ail  csiiccial    variety. 

'J'lic  so-c4illc(l  nephrotyphoid  lia-  al-n  licen  |invio!isly  considcnNl 

(|)|i.   1!''J,  I'.l.'l).       It  \va-  lliefe   meiili ll    that    its   >liar|)   ilitrcroiitiatioii 

liv  (iiiMer  and  IJoliin.  ami  e-peeially  the  -elieinatii'  cla— ilicalioii  ul" 
.\mat,  liail,  mi  cinder  -iiids,  priAcd  iintctialile.  .\c\  ertliclcss,  tlic 
desij^natiuii  ti('|iliriii\  plinid  m.iv  lie  aiiiiiieil  to  ceriaiii  ca-cs  as  dc^iTiliiii^ 
liricdv  and  well  a  |>eciiliar'iv  nf  llieir  cuiir-c.  Tliis  is  |icriiii— ililc 
— just  as  lias  liceii  |)iiiiitcii  out  with  rcirard  to  |itieiiiiiiily|)lioid  and 
lilciinityphoid — svlicii  the  comiiKiiecmcnt,  a-  well  as  ilic  tifst,  and  even 
till'  second,  wci'k  of  the  attack  is  dotniiialeil    liy  the  clinical  pictiiro  of 

'  ('.iiii)iiiro  the  Kriiirli  litiTiiturr  i.ii  ilii-  |i,.iiit.  )..  'J.'iT  i -fn  iiN"  p.  lis  In  ii.l.li. 
li.'ii.  til.-  iiajicr^  .if  N'.tUT.  /.■'(//.  ./.  /./  N...-.  III,'. I.  ill-  l-nr'n.  -Mny  1>'..  ls;iii  l,..rii:a  -uA 
I'.Ti.-uli.  Uiliirmii  infil..  18:10,  Xu.  -Jdi;.  W.intraiKl.  /.'.,■.',.;.  Kim.  »■■■■>■  .  \X'X'..  .N". 
1').      Spiri;,'.    Mitihril.  a.  klhi.    hisiif.  //.  Si-lnrrh.   18!l4.   1    It.ilie.    Il.t'l  ;'.      .-^uhli,  /An/. 

In  all  ill.- 1-.'*   ill.-  Hpli..i.|-l.a.-illii-   L'.o.-ri-.-   !■.  piiriil.-iil   i-H'ii-i.'ii-       That  il  may, 

li..vv.-viT,  iTiM-  rUi' aU.i  in  scTotiliriiiuin  i-tl'ii>inMs  i-i  nIiciwu  liy  the  oast- of  Kernel,  pre- 
■'-■•- -Urlv  iiliriiti'-ned. 


320 


I  y  nil  III >  II  I  /  /.■. 


s.Mr.     ;i<ii(,.    lHMi..rili;i.jic-    ii,|,liiiii-.       I'lii-ilirr   .Li-iiicMiJ,,,,,    h,,u,  v.r, 

M«  M-    Ic.    illcllMir   (.1-,  -    ill    Vllilrll    ||ir     ll-llal     l\  |,l|..i.|      I,  -|m11-  ,,('    ill,-    \  i-rclll 

""- liniriill^,   ;iii(|     ,x,.||    ;iil:ilo|iil,':i||\,   :,     s,,-,    ~iil  „  ,r.|iriMlc.    |..,-ilion, 

nr  lire  CN,  II  :il, Mill  (  ill  ir.  I  .  .  .11,1,,  :,r-  lo  Iiir  iiiiin-liCiMl.  I  li:i\,.  ,,|,-,.|\,.,1 
'■'-'-  "''  M.  |i|l|-Ml\|,||,,i,|  ill  uliirll.  Ml  lllr  r||<|  ,,ri|„.  ti,.,|  ,,r  Ml  lllr  iM-ill- 
'""-    "l''l"'   -'■'■ I    "'•••'^.   -■luni.'l.  ri-li,-  .liMIThrM.    Iui;,.|||rr    uitli    ,1, ,-,,|,s 

n.-..,lM- mimI    riilMrLr<tii.Ml  ,,f  ili,.  -|,|,.,.|i.  li,.,  Mp|..Mn.|  ;   mikI   I  ,-m,i  iv.^mM 

illKilll.l-  iM-c  lliMl  .llirill-  lite  M|.|HMl,,|  I,,  l„.  livr  In.ni  illl.-lillMl  illM.lvi- 
lll.'lll,  ImiI  wllirll  Ml  Mlllo|,-\  lAllil.il.ll  MllllllllMIlt  i  fl  li  It  I'M  I  !<  .11  lA'  I'.Mr's 
I''"'''"-  i"  'll''  l""'|-  lllil-'l  "f  III.'  ill'IIIM  M-  low  M>  till'  iji'u.'.'CMJ  \Ml\r. 
'I'llc     -iMh  IIKIII      mI-.i    lIlMl    ill,'    .M-.-    ill    ,|l|,Mi..ll     mIiiIM.I      mIumV-      I  ( •  I'll  lillilte 


ImImIK     i-    Mill    I'dlT'-. 


r'-.'i.  mimI  I-  nn.liil.K 


i|<i>ii  iii-iillii'ii'iii  lialM. 


1  Jiiiv.-  .l.-,rilM,|  nil  |,M._-,.  :;ii(i  M  ,'MM'  ..f  U|,l„,i.i  \\■^,■v  ,,f  Ml,..riiv,.  .',,iir>^e 
wImcIi    c'xImI.ii,.,!    |„.rli.|lv    ihr    rJinirMl     |,i.|i,n.    ..f     i„|,|,n,U|,|„,i,|       o,,lv 

r.'<'.'llllv    I      .,I,>,.|'V<'.|     M     >r,-,,li,|     ,.M>r     ,  .f    |1„.     silu,'     .  I  ,M  I'Mrlr  I',    '    A      MlcnllMIlt, 

tv.iiil\-Mv    u.Mi'>  o|,|.  ill  »!„,,,'   iMiinly  :;  «fll-,lfliiic.|   ,'iiM>  ,,r  |v|,li.,i,l  Cvrr 

•''  ' I'l-.iii' H'v.rily  liM.I  .M'.'urrcd  williin  m  >linri  linic  |.r.'vinii,«lv,  wms  scizcl 

Willi  .'-.'ii.siM.Ml-*  ot■^||i||i,|,.^s,  i;.||,,«,.,|   l,y  M  M,'|,-lik.'  .'liMilJoM  ■  .f  "l.'iii  («','Ml  lire. 

All.T   ll'c  .st'i'iMMJ   .lay,  I.I ly  iirin.'   .'..MlMiiiiiiLr    larLT   Miu.iUhi-  ,X  ;ill.iiiiiiii, 

Willi  irrcal  ihiiiiIhts  ..f  liyMliiic.  .'[.illnliMl.  mii.I  li|,,o.|-.'ii>l>.  um.s  vni.l.'.l.  'I'lie 
niM..iiiit  ..(■  iiriiiu  was  -r.'ally  <liiiiiiiir.|i.',|  iVoiii  :;no  i,,  Jliii,..,-.  j,,  uvoiilv-lniir 
hi.iirs— anil  llic  spt'cill.'  -raviiv  \\m>  L.-lucn  |(CJ'_'  ,iii.l  jIlL's  .\ltii..iiL'h 
<li.riiiir  III.'  tlrsl  i;.«-  ,lav>.  in  iIk'  al,>.i„.'  ..l'  „il„.r  ,'.„i,.,,i,„,,iis  svin|,t,.iiw, 
iinllniii:  i-N,.  iliMM  MM  M.iilc  li.'iii..rrliai.'ir  ncplniiis  , ',,1,1,1  |„.  a.-Mii'iicI  I.,  he 
I.rc.s,'iil._ii,'v.'rlli.l.>s  ll,,-  iHTsisK'ncu  ..fllic  trv.r,  lli.'  .Irv  I, .111:11,.,  aii.l  ..iilartre- 

in.'iil   ,,t   III..  >|.|,',.||.   ,l.'Mi,,iislralil('   l,v   |.al|.ali,.ii   on   il'i,.  (iftli  .lav.   1 .iher 

^^■"''  •'" <'iirn.ii<',.  of  111..  olliiT  caM'S  in  lli,.  >an.c  I„.um..  raix-.l  llic  .(ncMJon 

as  I.,  wli.'tlicr  III.,  c.n.liiioi,  riii;:lil  not  I...  .l.'|,<ii.l,.|ii  ii|„„i  ivplioi.l  inti-ilioii. 
I  111'  appcaran.'..  ,,f  r,is,.,,|;,.  „n  ti,,.  ninth  an, I  icnili  .lavs  of'liic  iliMasv,  ami 
tli.'ir  .'ontinucl  appcaran.',.  in  ahiin.lan.'..  up  1..  tli.-' foiirl..(.ntli  ,lav,  con- 
vcrh'.!  the  siispi,'i,,n  iiilo  .'.'rtaiiUy.  'i',,,  1,  ,  ;.,.|'M.,|,.,i  in  m  nio,l,.ratf, 
fonlinu(.,l,  rcniilUiit  tl.rni  iiiiiij  the  ,i-ht,.,.|,t|,  .lav,  ntter  wlii.'h  the  t..iniHTa- 
tiire  ahniptly  .|..,'lint.il  to  ;!t).;!'- < '.  «iihin  lu.-lv.'  ii,.iirs.  Fi',,ni  ihis  tini,.  on 
(■onval(.,..;<'(.n,...  was  nninlcrriipto.i.  'l-h.'  h|,„„l  ha.l  ,li>app.an.,l  fi'..ni  the 
urine  on  the  (.Ifvcntli  <!ay  of  the  .li-eiiM-.  an, I  i.lhiiniiii  an, I  tiihc-casts  ...iihl 
no  lonircr  h..  .i.-iiionstratcl  after  the  s..venle.'ntli  .lav.  J{,.lli  ,.as..s  may  he 
c.nsi.lered  as  typi.'ul  iiistan.'cs  of  lu.phrolyphoi.l  of  mihl  c.iirse.  If  I  am 
not  mistaken.  Hinilar  eases  have  heen  hut  rarely  iloeriheil  lier(.|ofore. 
ros.-.ilily  writer;  have  heen  t,.o  much  inllueneed  hv  iIk  eoiieeiitiou  of  a 
very  sev.-re  I'ours,    that   is  eonsi,|.'n.,|   typi,'nl   ,if  lli..'  ,lisea.-;e. 

'I'lie  pdsiti.iii  eli,,I,,i:i,'a!ly, ,f  cases. ,fii..plir.ilypli,,i,i  i>  as  yet  iiiiknowii. 
Tnist\v..rtliy  l).'i.'teri..i,,L;i.'  ex.'Hiiinati.ins  .lir<.<'te<l  especiallv  to  the  j.ar- 
tii.||)ation  of  the  typii<.i.l-l)aeilliis  in  the  kidney-lesions  liave  not  as  yet 
lieen   made. 


1 


\  .il:l  \  I  luss   l\   .sYMI'lnMS    I  \7*   (■nll;si:.  .'f.'l 

ASSOCIATION  OF  TYPHOID  FEVER   WITH  OTHER   DISEASES. 

N;imr;ill\,  till'   cjiK-tmii    liclc    <<{'  r-|w<  i:il    -i'_'llitic:ilii'r,  Mini  tlic  c.iic  t<i 

I tiii-ii|iTi<l  alKP\  (■  mII  iplliii*,  i-  :i.-  t<i  the  nliituni  li<t\v<iii  tlic  nllicr  :iciilc 

illicit iiiii-.  ili-ci-i-  ami  l\|)li'ii(l  t'lvir,  or,  inipii'  (litiiiiiciy  i\|irt'SM'<l,  tin' 
manner  in  wlm  li  liir  p'rirani-ni  nmlir  tlif  iiitliiciiic  nt'  tlic  ty|iliiii(l-l)acillii.s 
li<|)(i'liU  *•>  till'  ailii'li  111  llii'  -[Miilic  rxritinir  cailM-^  (il  llliisc  (lis«'ascs. 
It  lia.-<  pre  iiiii-l\  Ipcim  iiii|p|ia-i/c<l  in  tlic  <  icncral  STtion  (p.  •!■">)  that 
tlir  I'xi'-lciii'c  111'  l\  |p|iiiiil  liver,  e-iieeialiy  at  liie  jieriiMJ  ipt'  its  t'elirile  iieij,'lit, 
atl'iinl-  |p|i''v  eeilaiii  |pri)t(  .lic.n  a^ain-t  the  inva-iipii  ipI'  oilier  aciito 
iiireeticiiH  ili->  I  •  -.  A-  a  matter  nl'  I'ael,  the  lip||ii\vin>r  ^fatemeiits  will 
^hlp\^  that  ihi-  i-  eiitiiiK  tr;ie  with  re^rarii  to  j-orne,  while  with  re^^ml  to 
otiier-,  even  thoiiL'li  uitii  I'Mreiiii'  niritv — ,.r<,iiliiiUnii<il  nyii/dni — h 
(iiiiieideiiee   ol'   thi'   (li~c'a-e    with    the    lilstiL'iiiin    "i    ll"'    tynhoid    can    lie 

mail It.      'i"lii'   |HP— ilpilit\   ot'  inliition   diiriiiir    the  st;i)re  of  eoiivales- 

<eliee,  and  al-o  diiriiii,'-  the  jpcriod  ot'  ineiihatioii,  is  le.-s  to  lie  e\eliide<l,  as 
siK'h  int'eelioii  appears  to  1m'  distinetiv  niore  Irefjiieiit  at  this  time  than 
at   the   111  iv^ht   <pf  tiie  H  \  er. 

Typhoid  Fever  and  the  Acute  Exanthemata. — The  rpies- 

tion  as  to  the  eoineideiiee  ot"  the  aeiite  exanthemata  with  typhoid  fever 
is  still  ipl)>enre  in  many  re^peet-.  The  older  lilenitnre  contains  far 
nioro'mimerons  |MPsitive  statements  than  the  more  ns'cnt  litenitnre. 
Manv  of  the  earlier  re|Hiils  are  to  lie  aeeeptnl  with  jrreat  caution,  not 
alone  on  aeeoiint  of  the  often  mipst  iiidelinile  description  of  the  exanthe- 
mata, hilt  also  on  account  of  the  uncertainty  in  the  diagnosis  of  ty|ihoiil 
fe\(T  itself;  for,  as  has  liccn  |Hiiiite<l  out,  typhus  te\ir  and  typhoid  fever 
were,  until  within  rei'cnt  decades,  not  -iittieieiitly  ditlerentiate<l,  jiiirtieii- 
larly  in  Kiitrhtnd.  it  can  at  tlii^  )ire?'ent  day  he  stiite<l  with  consijleraliio 
cer'ii.iiiu  that  a  luimf.  '  acute  exantheiiiiita  may  detinitelv  he  asso- 
eiatwl  with  typhoid  fev<'r.  while  this  can  lie  deniiKl  of  others,  or,  at 
least,   the  (pie^tion   U   still   donhtt'iil. 

The  eoiiicidcnee  of  scarlet  t'cver  and  typlxpid  fever  lias  Iieen  recorded 
hy  nmncroiis  ol. servers  :  'i'aiipiii,'  i'"ipri;et,-  Miirchisipii,'  and  recentlv  hy 
f^ichhorst  '  and  (iliiser.^  Murchi^on  |>reseiits  the  lari^e  ninnber  of  H 
personal  ohscrvations,  all  on  |)atients  in  the  I^indipn  Fever  Ilosjiitrtl,  who 
were  infected  witli  scarlet  fever  from  other  patients  in  the  same  ward. 

The  fipllowinir  liistnry  hy  Murrhisini"  may  serve  as  an  illiistratioii  : 

A   iKilice-ottirer,    twenty-three    years  cpjd,   was  admitteil   to  the   Ixindon 

•  Jour,  (/--.s  ri.inK   mi,!,  rhir  .    18.30. 

'  L'entiritr  {..Um-u]..  ]»ari<.   1H40  (bntli  rilvd  by  Murohisnni. 
'  hur.  cil..  Hii.l   7'™n.«.  P(jt/i.  S,.r..  18.-p&.  vol.  x. 

•  Lehrbui-h.  '  Dmfwli.  ninl.  Il'.^-A.,  188.',.  N",.    11.  and  1880,  No.  40. 

•  'J'i/p>i"itl  DL-iriixr.^.  p.  £ii;i.',  trunslated  liy  /.iiIkit,   licrliu,  l»ti7. 

21 


Hi 


i  it 


Illi 


322 


TYi'iiniD  ii:vk::. 


FfVtT  II(i>|iilal.  Nov.  !t.  1^57,  atUT  an  illiif>,-  of  fru'ii  twu  lu  tlircc  wcoks' 
duraliiMi.  He  exliiliilcii  ail  tlif  sviiiiitdiiis  ut'  iNpiinicl  tfvcr  ;  a  nil.  irlazod, 
anil  tissurcil  iDnLTiic,  tyni|):inili'S,  ]irnt'usf  watcrv  liiarrlica.  ami  an  aliun- 
<lant  riiHi'i)liius  exaiuliciii.  l'"^^■^ll  .--jiiil.-i  apivearoil  ((nislanllv.  Kiirlil  davs 
litU'r  iidinission  tlirv  were  >lill  i)uile  nnnieruus  ami  tlie  iliarrhea  jier^isteil. 
Thore  now  ajipoareil  in  aildilinn  a  irenera!  .-rarlalina!  eniplinn  iilentieal  willi 
that  i)f  scarlet  t'evir,  tnL'ellier  with  a  straw  lierrv-tiin;:iie,  with  L'reatlv  cnlar^.'eil 
pil|)illa',  aiiLrina.  ami  reiiness  ol'the  t'aneis.  Alter  two  ilavs  the  rnseiihe  were 
!<till  ipiite  miinerons,  ainl  the  scarlatinal  eruptiiin  persisleii.  '1\mi  ila\s  later 
the  latter  tadeil.  while  the  typhniil  eriiptinn  persisted  tiir  a  lew  davs  inore. 
A  week  alter  the  disappearance  of  ihe  scarlatinal  eruption  there  was  ahun- 
<iant  ik'sipianiation.     The  patient  recovered  rapidlv. 

Anioni:  the  cases  of  ( Ihiscr.  one  that  terminated  in  the  death  of  the  |)atient 
is  e.<]>ecially  instrnciive.  In  addiiinii  to  ijie  tvphoid  fever,  which  was  char- 
act-'rized  sutticienlly  hy  roseohe  ami  palpable  enlarirenieiit  of  the  spleen, 
svtnjiloms  of  scarlet  fever  appeared  at  the  lietrinninjr  of  the  st'cond  week. 
The  well-nnirked  and  characlcri.- iic  cxanlhcm.  which  persisted  for  live  ila\s. 
had  heen  prccedeil  inunediately  liyanL'ina.  w  ith  ilark-reil  di.scoloralion  of  the 
mucous  inenilirane.  The  jialient  died  in  cunseinience  of  scarlatinal  nephritis. 
Kxaminalion  of  the  intesline  disclosed,  in  the  neiL'hhorhood  ot'  the  ileocecal 
valve,  the  h'sions  of  a  terminated  or  healed  typhoid  |iroces.s  ot"  sliL'ht  extent. 

I  have  |>i'r~iinally  imt  a-  yet  encoiintcrei!  the  coincidence  -d'  the  two 
<li-ea-c-.  |ii'iil)alilv  liccaii^c  I  have  ahva\  -  |)racli-cil  the  ri^iij  isolation 
<d  t\pliniil  |)atienl-.  even  of  aihilts.  i.'H'i  patients  -Mll'ci'inir  from  scarlet 
ll'Vcr.  With  rcLTani  In  the  order  in  time  in  which  the  diseases  -ncceed 
each  other,  a|iparently  in  the  o-reat  majority  i<\!  in-tance~  scarlet  li'ver 
occurs  secoiiilarily.  It  then  o-eiierally  iippeai's  in  the  later  st.-iircs  of 
tvplioid  fever,  often  iiiilv  diiriiiir  convalescence,  Imt  even  in  these  cases 
the  on-ei  i-  tVcipienily  -o  early  in  convalescence  that  the  jieriml  of  infec- 
tiiiTi  Dui^t  l)e  ret'errid  t(i  the  fehrlle  sUiL''"'  of  the  tyj>hoi<i  fever.      I'Voni  :i 

iliairnostic    ])oint   of  \li\\,   tin inhination    in    ipiesiion    present-   con- 

.siileralile  ilillicuitv.  It  i- easilv  conceivaMe  that  certain  cases  of  lieiuor- 
rliatric  varinla  witli  a  scarlatiniliirrn  initial  i\anthcni  .and  a  typhoid 
t'oiirse,  and  also  cerlain  -carl.itinoid  erythem.ita.  i-pecially  those  atlenii- 
iniT  crvptoi^-eiietic  -' pticiinia-.  max  he  confn-ed  \\itli  the  coniliiiiatioii  (d' 
ili-eascs  now  under  di-cii  — ion. 

The  coincidence  of  i-iiiheln  with  typhoid  fever  h.i-  heen  tiienti'inHl 
liv  Taupiu.  Iiarihe/  and  Killiel,  .and  other-.  \\  ilh  .ill  due  rei;ard  for 
the  .■iciuuen  of  ihi-e  ol i-erv( 'r-,  e-pecial  caution  woidd  -ei  in  nece-sarv 
in  ihi-  couucclion,  particularlv  nu  accmnit  of  the  dandier  of  confusion 
ot  thi-  ciuililinn  \\\\\\  ir.-ni-iiul  |innclate  er\theuia-.  .iml  especiallv  with 
ilruL''-i'>:antlienia-.  It  i-  donlilful  whilher  nieasle-  and  t_\phoiil  jl'Ver 
niav   occur   loi^rlhcr. 

In    ni\    exjierience '    variola    and    typiioid    fever    n])iiear    almost    to 

I  S' .  ('ur-i  hni:nin.  j*i-  {'"(k-'T,,  ■■■^u  /iffti.ssr}t's  Jhtnfihur/i,  LM '.-d.,  I87H.  Th. 
Siiii'in.  Hrrlin.  klin.    Unci,..   IsT'J.   N..    !l. 


If' 


r.iy.7.i77'/\s  i.\  sYMi'T'tMs  AM)  cnrnsi:. 


\vn 


cxclnili'  vM-\\  otiicr  (luring'  tlu-  trhrilc  -t:iirc  nf  'k\v\\  disoaM'.  I  Ijavc 
rciicatdllv  x'tii  I'lHivali-icnt-  tVorii  ty])liiii<l  liver  att:R'ki'<l  hy  >iiiall-])().\, 
liut  wlinicvt  r  iIk'  lnirimiiii.t.'  "f  ll"'  attack  nf  variola  \va<  (k'tiTiiiiiicd,  it 
(•(iiild  lie  i-talili>iifil  that  tlic  iiit'cctiiiii  liiu>t  have  taken  ])lace  in  tile 
ali'lirile  |ieri<Ml  .if  einivali'-i-eiiee  iVoMi  ty|)li(iiil  fever,  even  adinittinir  the 
limue-t  |i(i>-ilile  ]»eriiiii  iif  iiieiiliatiiin  iiir  the  xarioia. 

Of  ()  coiivalfM'eiils  frniii  t_v|ihiji.l  tever  iiifeeteil  with  Miuill-lmx  whdin 
oliservei!  in  the  year  l'"<7<'  71  in  the  hi)S|iilal  at  Mainz,  which  at  that  time 
was  i)vercri)Wile.i.  the  primary  :-iai:e  heiran  in  1  on  the  ninetetMith,  in  2 
others  on  the  scventeenlh,  ami  in  1  each  en  the  sixteenth  ami  the  fnurleenth 
dav  after  ihev  had  exhihited  the  la>t  fehrile  elevation  ef  temperature  attrik 
utahle  U  the  tvphoid  fever.  A  ca>e,  apparently  of  actual  coincidence  of 
variola  and  tvphohl  fever,  has  lieeii  reported  liy  Th.  Simon,  who  in  the  .same 
communication  .states  that  it  is  his  iiripression  that  durinj:  the  epidemic  of 
smaM-pox  that  prevailed  in  UandinrLr  at  that  time,  the  ca.-es  of  ly|ihoid 
fever  which  ()C<airre<l  exhihited  usually  well-marked  dcNclopment  of  the 
roseolous  exanthem. 

I  iiave  iier-onallv  oli-erved  vaceine-|iii-tnle>  durin'i-  the  felirile  sta<re 
<d'  tv|ilioid  fever  in  a  few  ca-c-.  The  iiiiueiii-  \ven>  individual-  wli  , 
had.  dnriuir  the  period  of  incniiation  of  i\jihoid  ll'Ver,  a  greater  or  les.s 
tinii'  liefori'  the  .-ippcarance  of  it-  tir-t  -ynipmin-,  heeii  -ulijected  to  pro- 
tec  lisc  vaccination.  'i'lie-e  ca-e-  jirove  thai  at  a  period  in  which  the 
oriraiii-in  i-  aircadv  inider  the  influence  of  the  typhoid  int'ectioii,  eNcil 
tiioULrii  in  !'Ut  a  latent  degree,  the  activity  of  the  excitants  of  vaccinia 
is  not  alioli-hed. 

Typhoid  Fever  and  Other  Acute  Infectious  Diseases. — 
The  Septicemic  Variety, —  Tlii-  ^verc  l'.>rni  of  disease,  which  ha-  as 
yet  heen  hut  little  invest igati'd,  appears  t<>  lie  tlu'  re-idt  ot'  mixed  infec- 
tion with  liacilhi-  tvphosus  .■ind  Stre|)toc(«'cMs  pyojrencs,  'Idle  eases  are 
-aid  to  he  cliar.icterized  hy  hiirli  tever,  nnu-Mally  marked  disturliaiiee  of 
tiie  irenerd  condition,  con-ideraMe  and  larly  enlarji-ement  of  tiie  spleen, 
the  nie-enterie  and  the  lironchial  ^-land-,  with,  it  ha-  Keen  -tated,  often 
oidv  sliirhtlv  <leveloped.  anil,  ai'coidinir  to  -onie  writer-,  at  lime-  even 
wlioUv  ali-ent.  specilic  inte-linal  lesions.  'l"he  pathoifcnii'  micro-ort;ani-ms 
are  denion-trahle  e-pecially  in  the  spleen  an<l  the  lymphatic  irlands. 
Thex  have  heen  1-epealedlv  fonn<l  al-o  in  the  liver,  the  hraiti  and  the 
nn'Mini,'!'-.  the  lunjrs.  and  in  the  hhwid,  e-pe<aally  tiie  Mood  ot  the  hmL''s. 
In    .all     the    lases   heretofore    reported     tiie     inviisioii     with     streptoeocii 

ap|icai'<   to   have    lieen     -i ndai'x'.      ( leiienilly,    purulent     proces-e-   :in<l 

ton-ill.ir  iinirinii,  otiti-  media,  phlcL'^inon-,  :iiiii  the  like,  due  primarily 
and  -olclv  to  the  -Ui  ptoiMcci,  c:in  he  dennuistr;ited  iiftiT  dcilth  :  while 
in  other  juirt-,  as,  foi-  in-  iin'c.  tlie  -pleen,  the  nie-enteric  e-foids,  and 
till'   liver,  both    varielie-     4'  piitlioiicnic   micro-orirani-nis   m;i\    he   found 


a 


u 


\^ 


iii- 


olit 


ryrii'iii'  ii:vi:i: 


m 


III 


toL'"'!)!!!' ;  ami  ill  -till  "\Wy  oi-iiaii-,  a-,  i'.ir  iii-lancc.  the  iiiti-tinal  fullirlc-, 
tv|ilMii(l-liacilii  ai'c  tVi  (jiU'iiily  t'oiiiul  .\\<i\\v. 

Tlic  (iiiir-c  uf  th"  ca-c-  ill  .|nr-li(iii  :i|il>cars  to  !>«■  irii.-t  \inilriil. 
Aliiiii-I  all    the   i-iM-    liitliiTtii   (ili-iTvcil    have  Icniiiiiatnl    tiitally.      It  i- 

.■(irrcctK    inaliilaiiifii.  i-iinially  iij llir  Ka-ir-  nl'  cxiicriiiiciital  oli-c  r\a- 

tiiiii,  that    the   ciiinliiiicil   activity  dt'  Imtli    iiiicni-iirpiiii-ni-   is   csiifcially 

(lanircnui far   iiicn-c  -n  tliau  that  nf  citlicr  alcnic.      I    have  iici-Minally 

ii(]  ('X|)criciirc  with    thi>  variety  of  typlmi.!    fever.      The   tir>t    and    iiio-t 

iiii|M.rtaiit  -tate lit.-  relating:  U>  it  eiiiaiiati   fn.in   Freiieh  invotijr.itur: 

('haiiteiiie->e  and  Widal,  Vaillard  and  N'iiieeiit.'  and  others.  They 
a|i|iro|)riatelv  de-iiriiate  it  as  the  Funm  s, i:lii-niii<iiii  (/,'iii'r<i/i.-;'r.  In 
(ierinanv.  \\a~-eriiKinn  -  iia.-  imlili-hed  -iiiiilar  oli-ervations.  He  \va.>i 
ahle  to  demonstrate  the  streptoeoeei  in  the  Mood  diiriii!.''  life.  l'"urllier 
investiiratioii  will  have  to  deterniiiie  whether,  as  is  highly  ivroliable.  a 
coiisiderahle  niiiniierof  eases  of  iy|ilioid  fever  of  inalijjnaiit,  fiilniinaiit, 
heinorrlia;.ne.  or  h\  |ier|i\retie  eoiir-e  do  not  lielont:  etioloL'ieally  in  this 
eatcLTorv.  The  ease-,  however,  in  which  the  ML'niinate  and  the  soliiury 
tolliefe-  of  the  int<-tine  are  found  entirely  free  tVoin  -iMvilie  infiltration, 
althoilfrh  at  the  sitne  time  ty]ihoicl-haeilli,  toplher  with  stre|>toeoeei. 
are  said  to  he  jiresent  in  the  other  or^raiis,  rei|iiire,  in  my  o|miioii.  caicfnl 
reinvest iirat ion,  whieh  -lioiild  lie  direete<l  esixcially  to  possihie  oinfiisioii 
of  the  tvphoid-liaeilhi-  with  the  Haeteriiiin  eoli. 

Ttiese  eases  are  to  he  sepr.nited  from  tlio-e  ea-e<  of  typhoid  fever 
wiiiell,  diirintr  t\w  defervescellee  of  the  fever  or  diirinjx  eonvaleseenee, 
aeoiiire  a  seeondarv  ^ih  ral  infection  with  one  oi'  the  varieties  ot  jiyo- 
irciiic  eoeci.  The  lei-.il  !iife<'tion  is  ]irotial)ly  favored  hy  the  lowcrtil 
jreneral  resi-taiiee  ol  the  patient.  The  jioint  t'rom  wiiii'h  the  orLtmisnis 
fain  eiitraiK'e  to  the  p'lieral  circulation  is  usually  some  lo<'aliz(>d  foens 
of  inllammation.  In  a  ease  lately  oeenrriii^'  in  the  .lolins  Hopkins 
IIosjMtal  the  jiatient,  during'  the  end  of  an  .ittack  of  typhoid  fever, 
siitl'ered  from  a  larjre  carhniicle  on  the  lia(  k.  Cultures  taken  from  the 
hloixl  dnriuLT  the  height  of  the  att.-iek  of  tyjihoid  -liowed  the  pre-eiiee 
of  tvphoid-haeilli.  Imt  cultures  taken  ten  days  after  the  onset  of  the 
carhiiiK'le  -luiwed  a  ])ure  ^rrowth  of  StaiihyloiMKcii-  aur«'iis.  Cultures 
were  repealedlv  taken,  with  -iinilar  result-.  ImI'oiv  ileath.  wliicii  occiiriUHl 
after  severd  week-  with  symptoms  of  ircnernl  septicemia. 

Of  other  conditions  allie<l  to  septic  ju-ocesMS,  erysipelas  is  worthy 
of -special  coii~ideration.      The  (K^eurrence  of  this,  uir  lui-  piTvioiuly  l.r<ii 

'  s,.,.  CliMiil.iM'-'i-.  ■■  Tv|iii.ii'l  f.viT.'  Trnit:  ilr  tv,'l..  pui'l.  pnr  (.'liftrc.t, 
I!>-u<!i:inl  .1  Uri-;uiM  t,  i.  lirmiiriUl  iuhI  Th.^ii"!.  ]<]'■  •-'!>:(  L':'4-  Viiirml.  A>w. 
,/,•  Ihistitnt.   fast,;,,-.   IS'.II!,  Nu.  '2.  ''  Ch'int.-Anualn,.   1W4,  t.  .\i\. 


I;  3 


V.[l:lATIo\S  l.\    SYMrrnMS  AM)   ((irnsE. 


inriitidiicii,  i^  not  ('\ilii(l((l  iiv  tlif  pit'xiiiH'  ot  tv|)liiii(l  ttvcr.  I  vjiimid 
|iatiriit~  at  any  staL'i'  tiiav ,  on  tlic  cunt  fa  ly,  lie  attackrd  liv  ei'y-i|>('lar-. 
lt"lliis  is  iiiiirc  coiniiiiin  tnwaiil  tlic  <n<l  <>['  tlic  tl  lirilr  jicriiul  an<l  diiriiiji; 
(■(iiivalt'sct'iico,  tlic  |iiinci|)al  rrasoti  tin-  ilii-  tifciiiiistaiicc  I'osick's  in  tlio 
tlu't  tliat  at  tliis  tiinr  Ixsl-Mircs  anil  iitiur  iilccfati\  c  pniccsscs  cdnstitiito 
c-prcially  tavofaiiic  -tai'tinti-|iiiiiit.-  li>r  the  |>nicr^s.  I  have  dhscrviil 
facial  crysijM'his  ilcvclop  (inly  witli  om-idci-aliic  rarity  at  the  hcitrhl  nt" 
the  disease.  This  nirity  is  <'speeially  strikinj,''  in  vie>v  of  the  ('rei|Ucncy 
with  which  cfi)si(ins  occur  at  the  iia-al  orilice  and  tiie  li|>-,  and  the  wav 
in  which  these  are  inallrcatcd  at  the  hands  of  the  p.itient  hiniself. 
Whether  this  nirity  is  due,  in  jiart  at  lui-t,  to  the  fiet  that  in  cases  of 
typhoid  f'ever  at  the  heiirht  ot'  the  jiyrexia  the  erysipelatous  infection 
is  soinewhat  more  severe  than  in  healihv  indi\  idual-,  tiiay  t<>r  the 
present  lie  considered  iiiide<Mded.  (iries^inirer '  also  has  noted  fiital 
crysijH'las   in   hut   '1   |ier  cent,   of  .')()()  cases  ohserved  at   Zurich. 

The  coincidence  of  tyjihoid  fever  with  Asiatic  cholera  is  mentioned 
especially  hy  'I'rousscau  and  a  niuiilxr  ol'  modern  I'Vencli  clinicians. 
].{,  however,  tlu;  suliject  lie  inve-tipiled,  the  condition  ajipenrs  in  most 
cases  to  lie  only  one  of  infection  with  cholera  of  convalescents  from 
tyjihoid  fever,  or,  couversclv,  ot"  tvpln.id  intection  in  |)ersons  who  a 
short  time  jirevioiisly  had  recovered  from  cli<ileni.  Actual  coinci- 
dence of  hoth  di>ea>es  ap[iears,  on  the  other  hand,  to  he  extremely 
litre,    if  it   occurs  at   all. 

Of    the   simultaneous    existence   of  dysentery    and    ty|ihoid    fever 
we   have   knowlrdiTc  oidy   throiitrh    iiie<lical    rcjiorts    from    the  tropics. 
Here,  also,  the  condition  ajipcars  to  consist  essenti:Hlv  in  an  invasion  o*' 
dy-cntery   dui'inj.''   convalescence    iVoiu   t\|ihoid    t'ever.      Cases    in  whi   ' 
dy-entcry   lias  devclopiKl  at   the  hciudit,   or   in   the  seeond   half,  of  the 

filirile  statre  should  lie  a pIiKJ  with    uM'cat    caution    in    the  alisenee  of 

caiN'ful  |Mist-morteni  examination,  ("olotyphoid  with  typhoidal  intes- 
tinal lesions  exteiidiiifr  far  down  to  the  rectum  mav,  as  I  liax'c  per- 
sonally oli-erve<l,  jrive  rise  to  symptoms  simiilatiiiii'  those  of  dv>en- 
tcry. 

The  loincident  occurrence  of  diphtheria  and  tyjilioid  fever,  par- 
liotllarly  duriiiir  severe  ejiidcmics,  is  mentioned  t're(|iientlv,  es[H'ciallv 
liy  older  writers.  Tloulitless  the  throat  condition  is  principally  one  of 
diphtheria  in  tli(>  older  anatomic  stnise.  Adeipiate  recent  liaeteriolofric 
investiiration  has,  so  fir  as  I  know,  not  yet  lieeii  made.  I  have  per- 
sonally not  seen  diphtheria — in  the  current  etioloixic  sense,  with  rhe 
deni(}iistr.iti()ii  of  the  haeilhis  of  Liiffler — Dcciir  a,s   a  eomplication  of 

'  /.(,<•.  cit. 


1 


li 


•V.  ■ 
?ie'' 


Itii 
It'. 


i-.'li 


lYIIInll)  I  JVIJ;. 


t_\|>liiii(l  fiAri-.  1  would  warn  (-[Mciallv  :iLrain-l  (■ont'n.--ii>ii  itii  tlic 
>|ii'iilir    l\|i|i'iii|    aliiiilia    |il'(\  i' ■i!-|\     iiiriil  ii'iiiil. 

A  iM'i  iii~i::nilii'aiii  /■:/.  i-  |ila_\ril  in  iln  n'M|iic-,  in  Ncpi'il.  Aniirica, 
(  liina,  aiicl  Japan,  anil  in  nialarinii-  ri  2i"n-  nn  llh  ■  ■inciit  nl'  l-jn'ouc, 
liv  ca-i-  lliat  Iwivc  111,  II  :itti-iliiitii|  til  niixid  inll  ■  itli  tv|p|ii.i(l  li-M-r 

and  malaria,  and  lli.-  Iiaxrin  Iran.v  lucn  d'  aalcd  tv|iliiinialarial 
U\iy.  |-'iMin  ihr  cM-iin-  dr-ci-i|itii.n-  (  Ki  Udi  nnd  l\  iimi',  S.  ii,  nliv, 
and  oiliri'- '  I,    the    ca-c-   ri|pfc~.  ui    an    ailniix  iiiiv    ,.1'  i\|ilioid    -\  ni|ii  'in- 

— n-iola',     |m:i— Mn|i-liki      -ii.i.l-.    -iii|iii|-.    dilTii-r    Lr..|i|.|iiii wiil,    il,,. 

I'lliiilr  cMin-c  iii.'nii.ir  In  innrniiniiil  liver.  .\' .urdini^K  a,~  ll..  uni' 
el'  llic  iiilici' (it  llir  twii  atl'd'liiin-  [ircdnininatc-  nv  rcci'dc*  tctnjMiraiilv 
nr  dnrin;.-  thr  rntiiv  i-niir-r  .t'  iln  di-r:i-r.  llif  ini.-l  \ariid  clinii'al  |iirl- 
iiiv.  I'l'lcn  dilliriih  III'  inirr].rilaii.in.  d(\  i'|..|i-.  'I'lic  c'oin>c  nt'  ilii~  ti.rni 
of  (li-ca-c  a|iji('ar-  tn  l>c  i|iiiii'  -.  mit,  .  iid  ii-  |iroi_rnii:-i-  i.~  >aid  to  iii'  t'ar 
iiiorrLiraM'  than  thai  nt'  -iinplr  l\|iliiiid  ti  \  i  r. 

I.viin.-  wliM  ha:-  -tndicd  ihr  t|ni-.ti(iTi  nt'  iMniliincd  1v|iliiiiil  and 
malarial  inlicti'.n  and  ihi  -.i-callid  ly|ih(, malarial  ti\(  r,  cdnrliidi  -  ihat 
in  rri:ii'ii-  wIhit  lioih  ai'r  ciimmnn,  it  i-  |ir(ii)aiilc  that  cnmliiiicd  intic- 
tiolis  nut  intn(|ncnll\  (iiiiii.  li,;t  that  -neh  ca-i:-  air  crft.ainlv'  imt  tiic 
line-  that  !ia\"i'  lice  ii  di -crilMij  in  ilir  I'nitrd  State-  under  the  n.ame 
'•  t\  |ihi'malafial  "  ll\'ef.  It  i-  ii  fiain  that  .■,!-(-  of  intei'inilti'iit  l'e\-er 
afe  inenffeetly  included  in  ilii-  i:f(iii|i.  lh.it.  withi'iit  the  intliiciice  i  in  the 
imdv  111'  tile  t\  |iliiiiil-liai'illu-  in  addiliuii  In  the  jih-inndia,  are  attended 
with  t\|iliiiiil  -\  tnjitiiin-.  -tujinr.  dcliriuni.  |iiii-tr:  timi.  etc.;  and.  cmi- 
\er-c|y.  -lime  |iln-ician-  |iract i-ini,'  in  malarinii.-  re;;icii>  are  in  the  hahit 
iif  c'liii-idcrinL;'  ca-i  -  ul'  t\  phnid  with  a  |)rcdiit!iinant  intci  :iiitteiit  tvpc  ot' 
level'  a-  inliuencinl  li\-  malaria,  ll  -In mid  lie  cm|ilia-i/ed  that  licliire  -ncli 
ciiniliincd  intectiuti  i-  ciin-;deri«l  a-  di  mun-trated,  the  |ila-mii<lia  -hmild 
lie  t'liimd  in  the  IpIhiiiI,  a-  Well  a-  a  |iii-ili\(' ( Irulier-W'idai  aL;i:h:tiiia- 
tiiiti-Ie-t  iilit.aiiied.  Italian  |ihy-ician-  and.  in  {■'ranee,  .laecnud  '  have 
de~ei-ilieil  a-  the  -iidiiral  t\  jie  i.r  t\|ihiiid  a  tiirm  nl'  di-ea-c  (.cciirrinir 
o~]ieciaily  in  Italy  and  .Malta,  in  which,  in  additimi  to  t'clirilo  and 
ty|ihiiid  >ym|itiim-.  intci  luiitciit  -weatiiiLr  a— nine- a  jironiiiicnt  ])osilion. 
.lacciiiid  consider-  it,  with  •j:nui\  rea-on,  a.-  a  |iecnliar  varietc  ot'  tviiho- 
malari.al  Tescr.  (  aiiinc  live  al-n — licvre  dc-  chieiis — wliicli  lias  hcon 
(icscrilied  in  lin-nia  and  Ilcr/cc-ii\  iiia  liv  a  nnmlier  of  oliservcr-  (Pick, 
Karliii-ki ).  appear-  al-o  In  liclinii:-  in  tlii-  caictrory.      I'rojiaiilv  the  condi- 

^  Mnliitlirt  ilrs  pniis  rhittnU.  I'ari-.  IS'-!',  <<liii|l.,',  I\  nn,  khrifrn  itfr  irnrmrn  Lan- 
der. .1.  ii.-i.    l""'.";       Scr  ihr  i-ntliiT  r\tin-iM    liiiniluii'  in  lln'  ji!i]M'ri  nt'  Imtli  writiTs. 

'   ,/n/|;,.<    Jli,/i/,{ll.1    JIi'S/l.    J>r/K,     Vnj.    \\U. 

»  Cliii.  mid. 


n 


\'Ai:i  \ni)\.s  IS  sYMrrnMs  ami  (i,ri:si:.  :vn 

tioii  i-  uiic  <it'  t\|)lM'iil  Icvn-  ill  iiuliv  iiliial-  \\\\<i.  a  .-imrt  liiiii'  |invii>ii.-iv, 
liad  rcriivtrrd  t'l-Miii  inahiria. 

Karliii-Ui  '    lias  di  mtiIhiI  an    iiitcrc-tiiiL'  ''as"'  "^  anthrax  (■iniiliiiicd 
witli  tv|ilii>icl  livfv.  wliicli  \va^  ^lllljl•(■Il•ll  tn  ixiivl'iil   liai'ttTiol(ij.rR-  fxam- 

inatioii. 

('a-(-iit'  (lie  (■..incident   .Ai-iciicc  ..t'  rheumatic   polyarthritis  w  iili 

ty|ili..i.l  ti'ViT,  wliirii  have  ex..  |ili.iiially  Imcii  r(|...rl<i|,  arr  l<i  lie  \if\v.Hl 

skciiti.allv,    l)fcau,-f,   ..li    tl li<'    lialid,  uc    arc  witliuut    |iatli(.;rii.irn..iiii' 

siirn-  ..t'  till'  tir-t-nainrd  .li-.a-r.  ami  (-|Mciaily  willi.nit  kn..\vlcd;:i'  of  il,> 
si)i'citii'  cxcitiiii:  t;i.t..r;  and,  ..ii  the  (itlnr  hand,  il  niil-t  always  In-  Imh-mo 
in  mind  that  tv|ilii.iil  I'cv.r  it-dt',  and  (.tlicr  (-(.nditidii-  cl.M'ly  rc-cniiiliiii,' 
it  -iiii.rri.iallv,  iiiav  at  tiims  ]»■  aiiciidcii  w  itii  iiiiiiti|ilc  intlainniat.iry 
atTccti..iH  III'  ihr  i..int-.  ,\in..nL'  llif  lattff  (•(iiiditi..n-.  certain  ea-.- nf 
erviitoLTcnic  -e|iti<'.i|iveniia  and  int'c<Mi.iii-  (i-tcdinycliii--  sli..ul<l  especially 
be  kept  ill  mind.  I  have  never  Ixmii  ahle  to  cnvinee  iny-elf  (if  the 
occurrence  of  eases  exhiliitinu-  a  coincidence  of  triii'  rheumatic  poly- 
arthritis   with   typhoid    t'ever. 

Chronic  Diseases  atid  Typhoid  Fever. — Xnininuis  refer- 

enee-  have  ]ii'evi(Hlslv  heen  made  to  the  relation  hetwceii  chronic  di.-eascs 
and  tvphoid  t'ever.  I  mav  aurain  call  atli  iitioii  e-iMcially  to  the  -:  ite- 
meiit-  with  ret'erenee  to  di-ea-c~  ol'  the  nervous  system,  the  circulatory 
oriraiis,  the  liintrs,  ainl  e-pti'ially  to  tiilierciilo-i-.  .VmoiiL'  constitu- 
tional disea-e-.  -jiecial  attciiti.iii  has  Ikhii  paid  to  the  eornliiiiation  of 
diabetes  mellitus  with  ty|ilioid  fevci-.-  .Vs  occurs  in  the  majority 
of  diseases  attended  with  clir..iiic  emaciation,  so  even  se\ere  cases  of 
ty]>li..id  fever  in  dialietic  |iatients  may  lie  attended  with  reinarkaldy  low 
tcm]ierature.  I  have  p.  :-oiially  oli-cr\itl  such  an  instance  in  a  patient, 
fortv-tlireo  vears  <ild,  who  died  as  the  nsult  of  the  attack  of  tyjihoid 
fever  at  the  hcirinninir  "f  'lie  third  week  ;  no  special  comiilic.itions 
oeciirre.l,  and  the  temperature  tlir..iii:h<iut  the  entire  ecviirse  of  the 
attack  did  not  e\e(rd  -Hi'  < '.,  and  reached  this  level  oidy  on  three 
e'-enili.rs.  !iOW  temperature  in  tlie-e  cases  is  therefore  not  in  itself  to 
he  considered  as  of  tiiM.ralile  sijrnitieanee.  Of  ()  eases  eulleeted  hy 
?'li-t<  in,  death  oeeiirr(.<l  in  4.  It  i-  worthy  of  iioto  that  the  excretion 
of  -II. '■ar  nnderL''i>es  little  ehanire  diirinir  the  course  of  the  attack  ol 
tV]ilioid  fever,  and  fjenerally  les.seiis  only  toward  tlu'  fatal  t<'rmination. 

'  lin-lin.  Idin.    Woch..  1888. 

=  (iriessini;iT.  Arch.  il.  llrilk..  1801',  ?-,.  .Iiihrff.  ^&m\>n<icT.\Vurzhur(j.  mni  7.fH.. 
180.1,  Bii.  iv,  Gortmnit.  Cfrrrx/nmi/nubl.  d.  ,i  rzfl  VrrciiiA  f.  //lurinprn.  18T1.  Bil.  iii. 
Rvl.ii  and  Vliliii.T,  I'mrj.  Virrt,-!]..  187".  Kbstciii.  Dndx.-h.  Arch.  f.  kiln,  yfcl  .  IW. 
.txx.  (Thi-  paper  ((.Titiiins  a  cimiplftf  clinical  discuesion  of  the  subject,  together  with 
full  rffcr.'iir-e  t..  tli."  litoruture. ) 


Hi 


111 


■f.  i: 


;;js 


7)  I  ■III  III  I  1 1:\  1 1:. 


On  til.'  (iiiicr  ii;iM(],  tlic  in>ii-cli|,,ri,|  rv;„.ii,,n  d'  ( Icilmi'di  ;iii|Mars  to 
nii(l.T.ro  a  .•un>iil(raMf  inl.M-iticali.iii  uiili  llir  cMiiiiniiir.HH  rjt  ..f  the 
I'cvcr  ((icrlianlt,    |-".li-triii ). 

Am. iiijr  til.' chronic  intoxications.  ivHrctic.'  ii.a\  1.,  rii:,(lc  t..  iikip- 
pliini-iii  and  alcolioli-tn.  S,  thr  a^  I  kn..\v,  attrniinii  ha-  Lltlirrl,,  not 
Im'cii  callr.l  to  the  l)ciiavior  .,f  |H.i-(,ns  a<lilicli.l  to  inor[,liin  toward 
typlioid  Irv.r.  I  have  >tudic.l  cantully  'l  cax  -  of  tyi^lioid  fever  in 
Mich  |Mr-on.-.  an<l  hav.'  \hv\\  iMi|iiv-.-,..i  ..>|„riaMy  will:  the  l,->ened 
))o\ver>  of  roistanee  of  sueli  indivichial-.  i'.oth  patient— tlie  one  a 
woman,  ihiity-two  years  old,  and  the  otiier  a  man,  tliirty->even  vear- 
old— died  a-  a  re-lllt  ..f  the  di>e:,-e  on  tile  tifteentll  Mild  tile  eijrllteeiltil 
■  lay,  ropeetively.  'I'iie  alisolute  -1,.,.|,|,.s-,m-<  from  il„.  i,e;;i,i,iine-.  tii<. 
eon-tant  mari<c^l  restiessne-.-,  and  tli<'  early  and  imn-nallv  pronoiineed 
suhsiiilus  leiidimim  and  tloeiitation.  -o  lliat  in  tlie  ea-e  of  tlie  woman 
tile  eoiKiilion  was  stronsxly  :-iiL'-,u(-tive  ot'  a  ea.-e  ot'  eiiorea,  were  eoii- 
spieiions  and.  of  eoiir-e.  ea-ily  e.\plainal)le.  'i"lie  temperature,  in  .-om- 
pari-on  witli  tlie  severity  ot'  llie  attack  in  other  re-peei-.  was  low,  jii-t 
as    in    tlie  eomhinatioii    of  diahetes   and    t\  plioid    i;\<r. 

Chroni.'  alcoholics  are  -erion-ly  threatened  when  atta<'ked  with 
typhoi.l  liver.  Ill  them.  al~o,  the  temperatiirc-.N.iiive,  iinle>^  complica- 
tions I'xert  an  elevatiiiir  inthience,  irfnerally  piir.-ues  a  rather  low  level. 
This  fact,  however,  ju-t  a.-  in  the  case  ot'  <liahetics  and  per-oiis  addicted 
to  inorphin,  in  nowi-e  alter-  the  pro^-iio-i-.  Alcoholic-  ;d-.i  exliil.it 
diminished  resistaner'  to  the  di-ease,  and  ireneially  -uecnmli  to  it  within 
a  s|i,,rt  lime.  I  have  ol.scrved  a  iiiorial'iv  ,,f  ;;  1  |„.r  cent,  for 
drunkards  suti;>rinir  from  typhoid  fever  at  llamlmr-.  The  lessened 
jM.wers  of  resistance  in  tlioe  paticnt>  are  cspcially  appreeialih  in  the 
action  of  the  heart.  Kvcn  from  tin  hcLnmiinL'-  the  |.iil-.  i-  likelv  to  h\- 
di-pro]Mirtionat<'ly  fn. |iicnt.  and  oficii  lieeome- di-iinctl\  -m.-iller.  Ilvhler. 
and  irrcirnlar  as  early  as  the  middle  or  close  of  the  lir-t  ..r  the  l.e-inioii!.' 
of  the  secoiid  Week.  Dilatation  of  the  heart  al-o  develop-  ,|uite  earlv. 
M'ilh  rei:ard  t..  tin-  vascular  sy-tem,  ihe  -jxcial  teiiclcncv  lo  hemor- 
rhaoes  is  to  he  considered.  Dninkanl-  exhibit  more  frei|Uent!y  than 
otlier  patients  copious  no-e-l)lecd.  and  arr'  otien  aliacked  llnu^uallv 
early  hy  sovorr  intestinal  lirm<>rrliai:e.  the  source  for  which  i-  eveiituallv 
found  to  consist  in  >poniriiies-,  friaiiility,  and  herni>rrliaL'ic  eonecstion  of 
the  patches  that  have  not  yot  imderirone  slou<rhinjr.  That  the  e.xces- 
sively  severe  eases  of  hemorrliai.'!''  typhoid  fever  occur  with  especial 
fri'i|iieney  in  drunkard-  has  Keen  previou-l\-  mentioned. 

As  a  further  pe<uliarity  ot'  typhoid  fever  in  alcoholics,  the  nnu.-nallv 
pmfoinid   involvement  of  the   eiiiiic  nervous  svstem   is  vet   to  be  nicu- 


v.inii  ri(i.\s  i\  sYMi-TnMs  .\.\t>  <(ii'i:si:. 


.•{2;» 


tiuiiiil.  The  cliiiiial  |)i(tiiif  nt'  ilic  ''atiixic  ail\  iiaiiiic  varirtv  "  ,i|i|M'ais 
(■:;rl\  iimlcr  tli(>n  coiKlitinii-,  willi  llic  •  arly  ilr\ cldjiniii.t  ><{'  |iiiilni,;:.| 
(li-imliaiiic  111'  iiiiiMi(iii-iii'>s,  jx'i'at  roilc-r-nc— ,  ami  -cvctr  ililiriuiii. 
S\  iiiploin-  111"  arliial  ilcliriiiiii  trtiiicn-,  luiw'vtr.  iHciir — in  <iiiii[iariM)n 
with  tlicir  rre<|iiriirv  in  ir\  sipcia.-,  piiciiiiiniia,  ami  ullirr  aiiitc  iiili  ctiDiis 
(li-<a-i's — with  rxtri'iiir  niiily.  It  M:.iy  riirtiicr  l)c  mcniiniicd  at  this 
point  that  allminiiiiiiia,  tint  laniv  al.-o  hriiii>riha;zir  nrphriti.-,  ocnirs 
c-pcciallv  carlv  and  in  inarhiil  ilitrnc  in  ilrimkard.-.  I'ndcr  tin-  ddi- 
ti'i'iiin-  intliU'iicc  of  early  cardiur  weakness,  the  latter  may  reudily  j^ive 
rise  to  fatal  uremia. 


VARIATIONS   IN   COURSE   DEPENDING   UPON    CONSTITUTION, 
SEX,    AND   AGE, 

Constitution. — Allhonjrh  defmite  kiiowledtro  is  waiitinL'  with 
rejrard  to  tiie  intimate  nature  of  that  wliieh  is  (le~ijriiati'd  eonstitntinn,  it 
may  nevertheless  he  staled  that  tiie  eoiiise  of  an  attaek  ot' typimid  fi\er 
stands  in  a  most  roniarkahle  relation  to  that  which  in  j^enefal  is  so 
desijriiated.  It  has  heen  seen  that  yoiinjr  vijrorons  inilividnals  of  ltimmI 
constitution  are  attacked  with  especial  i'reijiieniy  by  typhoid  fever, 
althoUiili  they  recover  most  readily  and  uniMJured  after  a  loiijrer  or 
shorter  course.  Toiiirh — that  is,  the  spare,  inuscnlar — indivi<hials  with 
healthy  internal  viscer-a  exhihit  an  espe<iallv  i'avurahle  relation  in  this 
<'unncction.  On  the  other  hand,  the  ohese  are  especially  threateiKHl.  as 
every  expirienced  physician  knows.  Oidy  tiMP  oi'tcn  have  the  friends  of 
a  coq>nlent  yoiini;  man  or  a  hloomini;,  tloiirishinir  yoiini;  woiimii  ]>lace<l 
too  mnch  de]ienilence  upon  this  deci'iitivc  appearance.  However  imich 
the  physician  tries  to  sn])press  iiis  anxious  fears,  he  sees  them  contirmed 
over  and  over  airaiii,  as  such  i>er~ons,  when  .attacked  with  tvphoid 
i'ever,  do  not  hold  out.  They  otten  exhihit  iimisiially  hiirh  and 
iininterrupteil  t'evi-r.  and  they  arc  early  overcome  hv  sopor,  coma,  and 
other  severe  symptoms  r:f'eral)le  to  the  central  nervous  system.  The 
most  unfavonihle  ti..;!  c  is  rhe  liehavior  of  the  heart,  which,  often 
as  (-arly  as  the  first  week,  exhil)its  si^-ns  of  deficient  power,  so  that 
the  course  ot'  the  disease"  is  almost  from  the  Ixyinniniir  dominate<l  hy 
the  siirns  of  cardiac  weakness.  I'pon  this  is  dependont  the  fact  that 
the  typhoid  hronchitis  of  the  ohese  earlv  attains  a  severe  deirree  and  a 
wide  distrihntion,  and  that  a  sjiecial  tendency  to  tlie  development  of 
pulmonary  stasis  and   hypistatic  pneumonia  exists. 

Sex. — (ieuenil  experience  teaches  that  no  m.aterial  difference  he- 
tween  the  two  pexes  appears  to  exist  in  reirard  to  the  tendency  to  be 
attackeil  hy  typhoid  fever.      My  own  experience,   based  upon  a  lartje 


].!U 


/ )  rihiih  1 1  vi.i:. 


liuriiliir  ot"  cMM's,  ;ii.'rci-  willi  llii-.  Al  <  \\\U\  nli  rciicc  to  ih,.  uu.,^. 
li(i~i-  (i|  tlic  .li-ca-c,  IK.  riidiial  dilli  rcucr  can  In-  ili.-((i\('ic(|  1,1  (Ai-i. 
^\  liil''  l.ii  1,1  nii.i-hi-  al  IJa-li'  oli~(  i-\,.i|  a  inorialil\  d'  |-_'|Mr  (vnl.  in 
mall  -  ami  cT  i  l.s  j,,,-  ,  ,.nt.  in  I'ltiiali-  ;  in  tlif  m.'di.'al  clinic  al  Mnnidi.' 
lor  ihc  _\car-  In. in  1^7  1  I..  Is77,  ..n  llic  c,.ntran,  the  nn.rtaliiv 
aiiioiiir  the  males  wa-  ci.n-i-ici-aMy  Lrrcan-r.      (ii.ili    aNo  rciii.rN  ti'...ii  ilic 

•  •linic  at  K  i,  1  a  m..rtalily  nf  ."..  |  |,cr  cent,  in  mal(  -  and  ..f  1..",  per  cent, 
in  tcinalc -.  1  lia\i'  |Mr-,.Tiall_v  l'..imd  llii-  relali..ii  t..  \ar\  in  di  'ivnl 
cilies.  'I"lm-,  al  1  lamlnn'L'  \\e  had  a  m..ilalil  >  .  .t' !'.!»  per  cent,  in  males 
and  (.1  S..".  per  I  eni.  in  Tenia  Ic- ;  w  hile  ..iir  -laii-iie-  al  I.iip-i.'  di-eli.-cd 
1  t.7  per  cent.  t'.  .r  il,,.  i',  .nn.i-  and   I ."..:.'  p(  i-  e.  ni.  ti.r  ilie  laliir. 

Ill  certain  eiti.-  and  in  certain  cla—e-  i.T  si.ciel\,  i.ii  the  (illier  hand, 
ditrennn-  in  ni]triii..ii,  in  iii..de  i.l'  lite,  and  in  i.eeiipation  appear  t.v 
eaii-c  appreeialile  ditl'ereiici-  with  rcijiii'd  1..  the  characler  dt'  ihe  eeiir-c 
and  the  leriniliatii.ll  i.t'  iheallack  ill  the  lUd  -exe-.  In  ihi-  ei.nnecliuii, 
the  ini]i.irlant  /■-'/.■  that  alci.hi.li--ni  |ila\-  in  men  i-  ( -.iieciallv  1(.  lie 
ci.ii-idei-ed.  Ill  wiiineii,  naturally — allhoiinh  thi-.  i.n  the  \vh..le,  iiiakc- 
iio  iiiipres~i.,ii  (.11  the  siati-tic- — the  -exiial  liiiictii.n-  are  ..f  lun-ideralile 
inlhieiice.  Ii  has  already  lieeii  -ecu  ||.,\\  ^r^ally  ihrealciied  are  preirr.iiiit 
Mild  pucr|Mral  wi.inen  altac  hed  liy  ly|ili..id  fever.  AIm.  diirimr  the  tir-t 
period  1. 1'  lactation  llie  jK.wer-  of  resi-laiHv  lia\e  appearc<l  to  iiie  to  lie 
-onieuhat  diinini-hed.  while  at  a  later  period  o|'  lactation  otheruisc 
\M'll-con-.titiited  Women  react  t.i  the  di-ea-e  a-  tho.-e  iiol  laclatiiiir  do. 
Age. — Tile  (iitlereiiees  dependent  Upon  iiL'e  are  I'ar  more  im|)(irtaiil. 
In   ceneral  it    may  lie  ,-ai<l   that    the  coiir-e  and   the   Urminalion   liecoine 

pron;res-i\-ely  mofc  nntiivoralile  with  iiicrea-iiii:  \car-.  >(,  that  children 

except  during''  the  earlie-t    period  of    lite oiiMlp\-   l.v   tiir  the  lilo>t    l'a\or- 

alile  -itiiatioii  :  while  a-  early  a-  the  iMrinniiii:-  ..r  mi<ldli'  of  the  lifth 
dci-ade    the    inllinni'i'    of'    aL'e    in-'jin-    to    make    ii-elt'    manifc,-l.      'I'Ih; 

inoderal iir-c  ..I'  the  di-.'a- eiir-  lieiweeii    the  (ifleenlh  and    ihiriv- 

tiftli   ye.ai-.      The   -o-called    typical    picture   of    the   di-ea-e   i.-  j-encialh- 

•  irawii  fn.ni  case-  dnrin::  this  period.  The  |ieenliarilics  ol'  tviihoiil 
tever  in  chiMri'ii  and  tiio-e  of  the  ili-ea-e  in  adv.'inced  life  docrve 
especial    ci.n-ideralion. 

Typhoid  Fever  in  Chiidhcwd.- — Apart  from  the  e;irliesi  period  of 
life,  which  will  re.vi\c  -pecial  con-idenition  later,  childnn  are  imi  mneh 
le-s  predisposed  t'l  typhoid  fcvei-lhan  adiill-.     Tlii-  predisposition  lie<;iiis 


m 

jlM^ 

'   nwlz.    n.;it..rh     .trrf,.    i.    klin.    M-.l  .    Ii,l.    \vi..    xvii..    \Niii. 

^  'I'll.'  |iiT<..iuil  c-xporii'iK-  iijK.ii  wliich  the  f. .lI..\viriL'  -tati-iiu-nts  aro  lia?0(l  is  dcriv.cl 
fn.i.i  til.'  ri'.'.inl-  ..f  f'.l:;  ni-.-.  iiTi.i  upcn  llie  careful  (tbservation  and  tri'atnient  of  2'Ji> 
ra>v<  in    li.i-|.i(;il   aT)i|   i.riv;it.'   pruiticc. 


IM /;/  I /7'*\N    /V   \)MITnUS     [\l>    (nfH^i: 


;;.;i 


-ImwIv  to  iri;ikr    it-i'lt'  riiiliccal.lc  a-  (••irly  a-    lniw.cn    ili<    t'..iiii|i  ami  llic 

lil'di  vcar.       A    I'lirlliri- ( -id' ralili  ,  ami  I'n'iii  llii-   linu-   "h    |irc.._:iv--.i\  ,•, 

inrrca-i'    in    llif    ijioilmliiv    ijvm-rallv   nn-iir-    lHt\M(  n    lli<-    niiitli   ami    ilii' 

liiilh    year. 

Allciil'hiii    -liniil.l    !«■  rallcii    I'.ilir   t'ac-l    llial    tin'   i  \|i('rirmc>   ni'  |.n\atc 

prariiiT   ami    llir   -lali.-lii  al    >lal(  iiiciil-    ntrrriiij    I"   llif   l'iih  ral    imi'iila i 

ari'  lar  mm>it  n  liaiijr  in  llii-  c.nmTi  imh  ihaii  lln-  ilala  nliiaiiic'l  iV'iHi 
L'l'iicral  lin.-|,iial-.  Naliii-ally.  iclalivilv  im.rc  ihiKlnii  iliaii  ailull.s  an' 
Ircaliii  al  Iimihc,  ami  ni'  tln.-r  aliarkr.l.  a  iMii.-i'i.  I'alile  nuiiil)cr  in  lai'Lir 
riiirs  i-iittT  llic  iliil'lrcn's  liii-.|.ilal-.  A<'(or'rniL;  I  \ .  llic  li^'urcs  t'xliiliiliil  liy 
llu'    L'fiiia-al    lin-|iiial    slali.-lir-   aiT    Inn    luu. 

Tiir  rliara<'tii'  i.f  ilic  (ji-ia-r  In  rliildnii  i-.  nn  the  wiiuK  ,  luililiT 
than  ill  adult-.  'I'Iha  afi  nmii-  iv-i-iatit  In  tlir  iiitn\icatinii,  and 
nV(  finiiii-  its  rlVci'I>  iiini-r  fiadiK  ami  innf.'  cniniili  l<  ly.  With  thi- 
(•nfrr-|><iiiil  tile  <'S|ii'cially  t'rr<|ncnt  alilifrs  iatinn  nf  the  di-t-a.-c  in  rhil- 
dfiii,  paflii-nlarlv  nf  it-:  tMifilc  staijfr.  and  llir  niuiai  laf^.Tf  iiiiinljrf  i>t" 
fcciivcrir-,    (  \'cn    ill    |ifotrai'tiil,    -cvcrc   ca-r-. 

Thr  ca-c-  ill  which  tlir  <li-ra-c  i<  i>\'  -linftcr  diiratinii  iiiaiiili-t  tlnan- 
»clvc-  in  \arinn-  wav-.  In  a  |H.ftinii  nt"  the  i-a,-r-.  the  -Imrinr  diiratinii 
aii])(^ars  to  Kc  dcpciidi'iit  ii|)nii  tlic  flicl  that  the  iiidividiuil  >taL''i's, 
althniiLdi  thrv  cxhllut  their  typical  dc\  (  ln|iincnl,  piir.-iic  a  >hnft«r 
course.  A  -till  lat'i^iT  iiiiiiilicr  liclnii^-  to  the  val'ictics  ot  typlmid 
lover  that  have  licm  dcsitriiatcd  alxirtisc,  mild  and  mililc-t.  which 
linvc  al"(idv  l"'cii  adc<|Hatcly  docrihcd.  Cases  nt'  typical  or  iireatly 
prntracte<i   cniir-e   afe    Ic--    cniunmti    in    eliildn  a. 

With  reL':iid  tn  the  t'elifile  -\iiipt(iinr,  and  especially  the  In  i^rlit  nf 
the  liodv-tenijieraliife,  the  curve  appear-  in  trt'iicrtil  tn  piir-nc  a  -nme- 
wlial  Inwcr  li'Vel.  Ill  i.'cneral  thi'  clcxatinn-  nt'  the  teiii|ieratiire  are  less 
in  vniiiit:  children  than  in  older  one.-.  After  the  iwelt'th  year  ot'  lil'c, 
the  curve,  with  relation  to  its  t'oriii  and  heiirht.  prn;_rres>ively  ajiproachcs 
that  nt"  adults.  The  tendency  to  a  markedly  rciniltent  eiirxc.  which 
makes  itsclt' a](i>an'iit  in  the  ca-cs  ot"  ahhreviateil  emir-e  and  nt' iiinderale 
.spveritv,  and  cspei-iallv  in  lliosi-  (.t"  protracted  eoiir-e,  is  iintewnrihy  of 
tvplioid  t'cver  in  chiMren.  ( 'ases,  however,  in  which  from  the  lictrinninLT 
the  curve  cxhiliits  siich  marked  ami  re^'ular  lliictiiations  as  to  lie  siiL'trt'^- 
tive  of  malaria  arc  di-tinctly  le-s  conininii  in  chihlrcn  than  in  adults. 
The  older,  ])articiilarlv  Knirlisli  and  I'^rench,  clinician-  ( Ahercromhie, 
Wcndt,  ('lioinel,  and  others)  early  de-ca-ilied  .-i-  intiintile  remittent  tcvor 
a  svniptoni-conijilex  occiirriiiii,  as  the  name  siiLTiTcsts,  prcfcraidy  during 
childhood.  This  was  at  first  considerfMl  a  special  disetisc,  hut  was  siihse- 
((iieiitlv  reco<;nizcd.  tlirouirh  the  lahors  of  Taiipin,  Rarlhcz  and    Hillict, 

W...:;f    .1.^.1    Mnf,.t.i^ni»     .1.;  t^-iiluiiil    te\-i.r  lii'  l^eelTliar  eeHlfse.       At    th-'t    tlinC 


El 


■/•)  ilinih  1 1  \  i-i: 


"'""''"'    '■'■■'I    iialiMv   nl'  InCniiilr    n,.  .iMn    l(\.ru;i-    ii..|    iindi  r-i I, 

•""'    •''-"    'I"'    al"'ni\.     ■ind    inilW    toi-iri-    u ,  iv    Kill     iiii|m  rl'.  n  K     kimun, 
i_\|ili"i.l   Wwv  ill  cliiMrcii   \\:i,-  cuii-i,!,  iv,|   i-.iiv. 

In    ruiiira-i  uitli    tlir    ii-ii:,l    I„I,:,n  i,  ,r   ,,r  il,,.    I,,  .,|v -i,  mi,,  r,,iinv,  ll„. 

|.lll-,-|-:i!.'     1^    rn.in     ill,.    iH-imiili-    •.dili-ly    lii-li,  ,-|M,i:ilh     i,,     ,:i||\ 

'■'''''" '•      **iil.^     ill    "I'l't-   .■liil,lin,,    ali.r   iIm-    tu,iril,    \,,i^    ,1,,,,.    ||,",. 

l.nU,-rr.,,iir,|c_v    .-.Liaiii    ai.|,r,.a,-li    that    ,,f    a, lull-.        In    -u,  |,    ,|,i|,|,vii 

''''■''•"'-"I    i-   "i-ii'iialK-  ,,l,-,rv,.|    in    lli,    ,,•„.   ,,|-  il,,,   -.,v,,ii,|   ,„■   ,|,.. 

tiiii<l  \\c,k,  wliil.-  I  liav,.  nitli  ,,iilv  (Ainiii,.  rarity  .■ii,oiiiil,r,  ,1  ilii- 
inanii;-tali,,ii  in  _v,,mii:cr  iliii.livii.  'I'lif  .•(,ii,liti,,ii  ,.('  llii-  Ik  art.  ,,1'  all 
till-  'ir-.m-.  rxliiliits  iii,,-.i  .li>tiii,'i  Is  llic  irnat.r  rv-iMiii!.'-  |«,u,.r  ,.l'  llir 
'■'"'''  '"  f'l''  •i'''i"'i  "I'  'III'  toNiii-.  Cardiac  Ural:.!,—  ,,.vm-  iiiii,  li  |,>s 
.•cmiiw.lily,  \u<\  ,.ii!y  in  rax-  .,|'  r>|„.,.i:i||y  |,,n-  an,!  ma.iv  c.iiis... 
Irtv-nlarity  ,it'  th.^  Inart'-  ,i,ti,,n,  a-  n,ll  a-  irr,-i,larity  ,,C  tli,-  pul-,.  in 
Iniv,.  .111,1  rliytlini.  i.  ,,|„..|-v,.,l  alin,,-t  ,,nly  in  tli,'  ,|nii,-  .A,v|,ti,iiial  ca-c.^ 
ciniilicatiil  liy  ,ii,|,M..ir,lit  i-,  niy,,i'ar,lii  i~.  ,,r  |,cri,':iriliti-. 

\\  ilh  n-ani  |.,  tlic  iiiaiiir,-tati,,n>  ,,ii  tif  part  ,,f  tli,.  -lun,  .■spciallv 
tho  r,,-, ,,!;,..  tli.v  ,\|iil,it  little  <l,viati,,ii  tr,,in  tli,.-.'  in  .hlnlt-.  I  kii,,w 
\v,ll  lliat  ni,,-t  ,liv,-r-,'  ^lal.'ni.nt-  liav,'  l„,ii  ma, I,-  hy  \Mii,.r-  ,,n  |M,li- 
atri,-.  -,,  that,  t;,r  in~taii,-c,  iJilliit  aii,l  I'.artli,'/  ,m,iim,|,t  lli.m  a-  raiv, 
wliil,'  'i'.iiipin  an,l  ,,th,iv  .•,,n-i,l,r  th,ni  a-  .mmih  riii-  witli  aliii,,-t  -ivatir 
fV,  ,|ii,ii,.y  than  in  lat,r  lif,  .  i'r..l..iMy  ili,-,.  ,lin;ivn,i-  .iiv  .•ittrilmtal,!,. 
to  a,vi,|,.ntal  l(„'al  .in, I  tiiiip,,ra|  ,-,.ii,liti,,n-.  1  (iiriiiL'  ,-,.ini'  ,pi<!,.nii,-.  ,,r 
'"'''•'"''■-  'II"'  l-"-i"l:i'  app,.aiv,|  aU,,  f,  Inr  I,,  l„.  |,.-.  pr,iii,,iinc,.,|.  uliil,. 
at  ..tlicr  tini,-  ihiyuciv  , -p.vially  cuiMant  an, I  alMin,lant.  If.  li,,u- 
•  ■v.'r.  r  tak,'  th,'  av.i-a-,'  .,f  many  y.'.ar-"  ,,l,-,rval  i,.n.  I  li,.|i..v,'  I  .am 
imalii,'  t,,  ap]ir,viatc  any  <li:i;  ivtiiv  In, in  tli.^  ,',in,liii.in-  in  a.liilt,-. 
l'o--iMy  it  may  \>v  Mat.-,!  a^  n,,tr\\,,i-tliy  tliai  tli,-  r,,-,.,,|,a.  Lr<ncr,allv 
api„  ar  -,,ni,u  liut  later  in  <liiMnii.  -,.„,.,.;, ]lv  in  -li-lit.r  ,,r  Iml  nmilcrat,' 
prutiiH,.ii,  lint  in  in,li\i,liial  in-tan, ■,-  ,,|t,n  ni,,iv  iiiark,,||\  .|,v,  l,,p,',l. 
r  have  l„.,n  -triK  k.  in  a  iMnnlur  .,f  ,'l,il,|ivii  iiftuc'ii  tlio  aire-  ,,t'  five 
an,l  t,'n  y.-ars.  I,y  tli,.  ,<p,.,aal  .-i/.c,,f  th,-  r,.M.,la'  an,!  tlii'ir  iii,-v  mark,il 
clcvatiiin  aliovc  tli.'  -nri'ac'  ,it'tli(.  -kin,  and  l,y  tlicir  tcn,l,n,'y  t,,  l„v,,iiu- 
fDnHiicnt. 

.\lin,,-t  tlic  snmo  tliat  lia-  iii.-n  -aL!  ,,!'  tlio  r,,.^f<.la'  i-  ap],li,al.lf  al.-^o 
to  -ii,!aiiiina.  r,irti,nl.irly  in  mi,l,!l,-  ••liiklli,,,,,],  iHtwr.ii  tin-  fiftli  .and 
ti'iitli  yi'ars  I  liav,'  n,it  ran  ly  ,,l.-<.rv<il  iip,,n  llic  clirM.  tli,'  al)(l,.m,ii, 
am!  ,l,,wn  to  t!io  tliiirlis,  nitticr  at.nndaiif.  in  p.art  <'v,n  r<,iiflii,  „t,' 
iniliaria.  witli  .Mil.>(M,iu.nt  <l.'s,piamati,.n  .,f  tlic  -kin  diiriiiL-  c.nva- 
li'Sfvnfo.  tlie  dp-i|iianiati,.n  l.tinLr  on,Mi  ,,('  .a  liraiiny  cliaractcr,  and  lirrc 
and   t!iirc  even   iHciirriiiL''  in   slicct.-  of  cin-i,!,  rai,]..  ^i/.. 


I  \i:i\ii'i\\  i\  M  !//■/■'/ 1/\    i\7'  ii,ii:si.  •!•'!.". 

|;,.,|-,,,rr-;  all-  iiiiicli  |-:(ltr  in  w  rll-iiiir-ri|  iliildn  ii  tliMii  in  adiill-. 
Niiiiia  w.i-  t'i>i'inirK  iii.iid  nilliir  lVii|iic'nl  ly  :i-  a  rofii|ilical  idii.  i -|m  ciallv 
in  MiMiiL''  'liiMii  II.  uImIc-  at  llir  |iri-cnl  day  tin'  londilidi  i-  -cair.  ly  i  \  i  r 
rit'i'frnl  (m.  I'iu'Ii  'li''  li'niliiHV  nii  iIh'  |iait  nl'  cliiMfcii  -ntliiiiiL''  I'n'tn 
Isplinid  li-vi-r  Im  piik  al  ihr  liii-i  aiicl  at  llic  li|i--  i-  di|M  ndcnl  llic  tart 
that  cxtcn-ivr  lili'i'dintr  ti--ni(-  and  r\(  niiali"ii-  idMnd  \s\\\\  iru-ln 
tVii|U<iilly   (Mciii-. 

Tlic   al>diiniiii    i-    niorc  likilx    |.i   lie   di-lriidi-d    in    cliildnii.  Iinl    ;.'rn- 

<Tall\     i>nlv    in    i Icrair    dcjirr,    and    ranly    m'    ;.T<'ally    a~    in    ailidt-. 

( 'liildi-cn  i'oin|ilain  nioiT  |Vi(jnriM  l\  lliaii  llir  laltrr  ot'  alidnrninal  pain. 
\'iiniilinir  :iiid  rclrliiiii.'- ,irr  not  \  i  ly  rafc  nianili^ialion-  nt'  llic  lii-l  li\v 
ilav-iit  the  <li-ia-i'  in  \cinnLr  iliildnn.  Willi  rclrrincc  to  tln'  nnniluT 
and  till'  inn-i-I<'nrv  nf  tlic  -tcml-.  the  cnndit ioii^  in  cliildriMi  cxiiihit  little 

iHculiarit V.      l'ii-.-iMv  diarrhra  i--  -nmowliat  inofi n>taiil  than  in  adult-. 

Oi-linrt  jircnliaritif-  <'\i-l,  liMwrvei',  with  fi-ii-ard  tn  thi'  -crinn-  intes- 
tinal inanil'e>Iali(Mi-  <it' henii>iTha<.'e  and  |iei'|ipnilive  jierituniti-.  lidth  are 
le-s  emninon  in  children,  e-pi'iaally  in  early  and  niiiMle  ehihllnMid,  than 
-dinewlial  later  in  liti'  (Taiipin,  livelier,  IJilliei  and  IJarlhe/,  ileniH'h, 
•  ierlianlt,  Hieilerl  ).  \\  liile  arncinL''  :idnll--  !  have  at  limes  ene(innlere<l 
hemiirrha^e  in  H'  |ier  cent,  and  e\cii  more,  ni  ehildren  I  have  nK-erved 
it  ill  urilv  i  |ier  cent.  Uiedert  also  states  that  in  a  enlh  cti.m  of  i:)'i 
cases  (if  tvjihoid  I'evcr  in  childnai  In-  round  iiite-tinal  heinorrhai;i'  in  not 
I II lite  4  IHT  cent.  I'ertofati\  e  j)eritoniti>  i-  eom|)ar;itivcly  even  rarer. 
This  ]>ociiliaritv  tinds  a  -ati-l'actury  cx|>lanalion  in  the  anatomic  condi- 
tions in  the  hdwel.  In  children  the  inliltration  of  the  ag-minale  and 
solitary  fullielo-  i>  in  irciural  far  le>s  inarkol.  Accordin;.l\ ,  -loiii^hin^ 
and  iilceriitioii  will  occur  under  >iieli  cireiimstaiiec-  iiiori'  rarelv,  and,  if 
at  all,  in  slighter  evteiit  and  to  a  loser  de|ith  ;  hut,  on  the  other  hand, 
it  imiioiilitcdlv  more  frei|iiently  ha|p|>en>  that  the  niedilllarv  <\vellintr 
nnderirocs  involution  thronirh  ahsorption  without  di-inteijration.  The 
incscnteric  ^rland,  an'  al-o,  in  p'lienil,  less  inarke<lly  -wnllcn.  ami  only 
with  extreme  r.irity  are  found  in  ,i  -tate  of  softeninjr. 

Th«'  ('(nniition  of  the  spleen  exhibits  iid  material  ditference  from  that 
which  occurs  in  mature  life.  It  may  |)o--ilily  he  stated  tl«U  enlarir"'- 
ineiit  of  the  s|(leeii  at  an  rarly  p«'ri<>d — that  i>,  before  the  bt-LrimiiiiL'  or 
the  middle  of  the  sei'ond  Week  of'  the  di,s<'ase — is  less  common  in 
children  than  in  adults,  ami  that  it  does  ndt  fre(|uently  exceed  niodenite 
|iroportions.  In  my  <'X|M'ri(Miee,  actual  |K'rsi>fent  alisi'iiee  ot'  splenic 
('iil.Trijenient  or  of  the  |K)ssil)ility  of  it>  demonstration  has  been  I'lither 
l(ss  coninioii    in   ehiiiiren    tlifin    in    adults. 

AmoiiLT  atfections  of  tlic   rcspinitorv  dr<riiis,  tvphoid  broneliitis  docs 


iS 


ina " 


H 


;i 


/ )  rit'iii,  1 1  ill: 


ti"i  'lillT  will,  r.i;  nn.r  |,,  iV,,,,,,  n.\  mimI  .m,  i,t  i,-..,,,  tl,.ii  of  L,i.t 
I'"""'-    "'     ''•'■        '"    'liil.livii    al-n    it     i-    ,„,,    ,,r    III..  Mi.xv  \„IiimI,1.'  .li.l-- 

""-'"■    ->'"l""i"-    "'     'I"     .li-.i-..        Il     I-    :, .i:,i,..|    nitlMT    liv,|u,,„U- 

uilli  at.l.-.|:,-i-  and  l..l„ilar  |,ii,  iiMi,,Mia,  ,-|„,  ialls  i,,  ,|,  l,ili|alr,|  rliilclivii. 
Sirnpl,.  aii'l  InllaiiiinalMiN  lu  |„,-tM-i-  nf  ||„  Iunl-  i-,  lh.«,v,r,  all  ilic 
iiiMiv  ran-  a  lact  lliat  -lir.l-  a  -tn.n^r  |i^,|„  |,,„„|  ,|„,  |;,v,,ial,l,.  -lal,.  ,,f 
111-  li.ail-|»,u,i-  ill  rliiMr,  ,1  lliat   lia-  Im,!,   r.|Ha|M||v   iK.irilcl  .,iit.       'Inir 

l"l'-l'-.    lil'lillMU-     |M|.  IIMInlila     I      liaV..    ,,l,,..rv,.l     1,111     .   \r,|,|i,„|alK     III     rjiil- 

'liMi.  I'l,  Ill-ill.  an. I  .iii|iy(iiia  al-..  aiv.  an  ..njiii-  t<>  llir  -lalciiiciil-  uf 
iii..-t  ,.l,Miv,|-,  ami  niy  nun  .aih  lini,-,  ,  rvlalivdy  iiiir.,riiiii,,n.  •riir 
siinc-  -lalniMMl  i-  a|.|.li.aMr  al-M  |,,  ati;.|  in,i-  ,,1'  ihr  larynx,  l»,ili  -iiii|,|.. 

"'•"'■"' ''  '!"■  iiinr,,,,.      hiiiliraii,' and    |Hri,linndriti-.  and    iic-n-i-  of 

llir  rarlila-.'.       A-    lia-    l.i.n    |»mih'<l   <.i,i   uiil,    p-ard   t..  a  .•nn^idrraM.' 

"i""l"i-"''  "ilirr  .■..ndilinii-,  il,,..,.  laiMipal  all'r,'li.„i,  I,,,- ■  >,,nu\N  iiat 

iiiMiv    |'iv.|iu'ii|  ai;aiii   in  I  il,  r  .•liildli,„,d. 

I'll'    -yin|.ioiiH   (.11    III,     |,arl  of  tlir   n.rvnn-   -\-i.ni  n-na!lv  varv  i„ 

■'•''"'■''■• ^^''''    <!"■    -'•vcrilv  ,,r  ||„.  allark.       |„    mild  and  .•v.'ii  ni.Hl.r- 

atrly  -rvriv  .-a-,..  t|i,y  ,,iv  ivIaliNrlv  -li^lil  — u.^mdl v  Car  I,-,  inarkrd 
'''■'"     '"    ■"'"l'~-       III    '!"■    •■"■l.v     |"ri.Hl     ihr     cliildivii'  aiv    ill-t,.i,i|«n-,|, 

''■'■''■'''''••I'"'    larriinn-,   ;    tiMAMil.-,- nils    lM-,-,„nr   dull,  apathni..,  aii.l' 

iH-iv  Ml-  l,.-s  -tn|,id.      Til,'    -rvnv  ra^,-.  I„,u,.v..r,  -,„n,liiMc^  s,t  in  with 

<-nnvul-ion.,  and    ,  ,  m  diirin-   lli.ir i-.,-,  r-|.,Tially  in    oldrr  cliildivii, 

"I'lcn    •■xliiliit    alarniiiiir    ~yin|.toin-.      Ai i--    t!ir.~<'    >yin|il,,iii>,    m-vciv 

li'nda.lir.    ri-idiiy    ,,(■    tl„.   n.cl<    and    l.;i,-k.    ^vncral    liyiMn-Mlic-ia,    willi 

-Iil-Vi-Iin.-,  dilatation,  and  rvni  in,,|ualily  nf  tlir  |.i,,,il>,  and  pruf, j 

.tn|».r  i.ro^rn.-in^r  i,,!,,  dr,  ,,  .nnia,  -Imnld  .-|M,.i,,||y  |„.  iii,.riti.,n..|. 
N,i\on~  -.•,|ii,l~,  -iich  a~  >|,inal  air.vtion-,  nniriti-,  and  <Tivl,ral  .li^tiirli- 

.■inr,.~,  c-iMvially  |.-.y,'liu-r-.,    arc.    mii    iI tlnr   liand,  .■uniparativilv  ran- 

ill  'liildrrn.  NmraLdr  di-ordcr-  al-o— li.r  iii~lan.-c,  tlic  di>tn~.-intr 
Jiam-  in  tlir  IkcU  and  Km-  mi  trn|ii.nl  in  adult>--|,a\  .■  |)racti,-allv  not 
"■iif  inidrr  iii\  ul,-crv.iti..ii  in  rliildivn.  It.-fciviUT  may  liciv  1„.  made 
a-aiii  In  llir  a- y<'t  iiiic\|,laiiird  Iraii-ili.ry  a|ilia>ia  (|i|..  27."i  and  L'Td) 
'•'■ruvvhvj  altnn.i  ,A.-lii-iv.|y  in  .■liil,||„„,d,  whicli,  altlKMi-li  nimtii.n.il  l.y 
•■••irli.  r  ,.li-.rv.i-,  lia-  ivnntly  I..-,  a  airain  {Miintcl  .nil,  |particiila-|v  ],y 
(iirliardt   (Clani-    I»i". )  an<l    Kiiliii. 

\\'iili  ivirani  lo  the  r,,iiditiun  of  tl„.  ,,rj_r.ans  ..f  s|)(Maal  -cii-r  in  ca^.s 
of  l\|,li,iid  ll-vcr  in  cliildliiMMl,  littlr  i-  known,  <..  far  as  I  ,iin  iiiloriucd, 
uilh  n-ard  t..  the  ,■■(■-.  'lyiilioi.l  atll-.-tion-  of  ||„.  ,.ar,  l.otli  tlio-c  of 
iicrvoii-:  oriirin  and  tlio-.- a-o.iatr.l  « iili  .-.trrctioiH  .,f  tlic  ii,i.,.|,liarviix 
and  Kn-taciiian  tiilic,  a|i|Mar  to  \,v  not  I,-  frc|iieiit  than  in  adults. 

liic  kidn.y-  .ire  comi.arativcly  rcM^taiit  diirinj.'  cliildliood.      |-VI)rile 


I    l/.7l//"Vs    l\  s)  t//'/"Uv     I  \7(   cnrnsr 


f! 


MlliiiiiiiiiiiriM  i-  i|i-liii<ll\  Ic--  c(iniiiii)H  :it  llii-  liiiu,  Mini,  il  |iri-<!il  at 
.ill,  i-  -lit'litcr  ami  "I'  -liMitir  diinilidti.  AiIiimI  iH|.liiiti-  M|i|":ir-  \n 
ucciir  lull  (Xci'iiIlipnalK  .  I  lia\c  |>i  T-(iri:ill\  tili-rrs  cil  no  <a-f  ot  tii.- 
kiinl    ill  A  riiilil.      'I'lir  dia/'       acli'iii  i.t'   I'liilii  li    i-,   a|i|>aniitlv.  aliim^t 

mvir   aiiMiil    in  c  liiMI <l — a  I'arl    In  wlii.  Ii.  in  \\i\\  i<\'  llic   liiiiilali"n- 

iircviiin-K  inriili'iiKii,  nut  inriui-iilcralili'  'li.iL'Hu-tir  -ii.'nitic'aiirf  i^  tu  Ix' 
!lttaili<'.|. 

'Ihc  iliiratiiiii  111' t\  pliiiid  t'cMT  in  cliiiilliiMKl  i-,  a-  lia~  Ixin  prrv  inii-iy 
inilicatol.  <in  tin-  uIh>1c,  -liorltT  than  in  iulnli-.  I 'niloiilit<<ll\ ,  tlic  iiiii<l 
and  alxirlivc  ca-i^  aii'  ivcii  niuii'  i-niniiKiii  in  iliildicn  ;  and  tlic  wdU 
(IcvcIuixhI  ca^i-  (if  -I'MTr  nii-it  iriiK'ially  triiiiinatc  earlier  than  they  di> 
in  later  lite.  Thr  alili'i\  ialinii  athct^  all  -ta^'e-  ot'  the  di.-ea>e,  Imth  the 
t'ehrile  jiericMJ  and  (■•invai.  ••■me.  Tlie  tehrile  |H'riiMl  ill  \vell-i|eve|(i|M'd 
Oii.'-cs  is  likelv  to  lie  -hiirleiieil  at  lime-  in  all  its  staire-,  while  at  (ilher 
times  (inlv  nlie  iir  allnlhtr  st;|i_rc'  i-  -lldl-telled,  e-]M'eially  that  nt' aseeiidillLr 
tem|)eraluie  .ir  that  lit' det'erve-eellC'.  It  i~  illtele.-till^r  that  the  (iliralii  ill 
(if  the  fever  ill  Well-marked  ea>e-  a;'|iear<  In  lie  -lidrter,  mi  the  wlinle, 
the  Miunirer  the  child.  In  ehildicn  lielnu  the  aL'e  ('f  six  years  the 
diiratioi.  miieli  le-s  ediiimiinly  e\ee<'(l>  tlirei>  week-  than  it  >\i*'^  in  nlder 
(•hildreii  ;  and  even  in  the  latter,  ditVereiiee-  '\-\  relatidii  In  a^'e  are  likely 
td  make  themselves  distinctly  manifest   in  tin    inanner  indicated. 

'l"he  fdlldwintr  tahle,  ha-ed  ii|hiii  the  ca-es  iili«erved  at  Hamlmr^ 
fnilii  1"<?<(I  to  1SS7,  is  uidst  in-lriletive.  (  >f  \  \'\  children  lietweeii  tile 
aires    of  two   and    fdiirlun    Ncar-^,   the  diii-ati(in   (if  the   lever  was  : 


ifi 

* 

% 


Vy  |.i  '.'I  iliiN- 

Iti'tw 1  '-"-'  :uiil  ■!■!  ilu\- 

M'lrij  th!iri  :i:i  iliiv^ 


■_' til ;.  vfjirB.  r.  Ill  I'l  years.  In  In  11  ycar^ 

•XI  |»r  ri-nl,  71  s  ]>,r  .cnt,  ('■"  s  per  cent. 

4  is  i;  L'.^i  7       •• 

•1       "  7.7       '■  11. H       '• 


The  -liorter  diiratinii  of  the  fever,  the  irr(>ater  resi.-tanee  td  the  actidii 
of  the  tdxiiis,  and  the  lesser  fie(|iiency  and  severity  ot'  i'(ini|ilicatidns  are 
res|i()iisil)le  fur  tiie  fact  that  cdiivaie-ceiice  i>  in  ;.;( iieral  c(im|ileted  earlier 
in  children  than  it  is  in  adnit-  This  ajiiilie-  not  diily  Id  restdratidii 
(if  the  -irncliire  (if  the  atl'ecte<l  (ii'iraiis.  lint  alsd  id  restoratinn  of  the 
former  -tale  (if  iiiitritidii,  especially  a  retnni  td,  and  not  rarely  e-.cn  an 
iiicrei-e  lievond,  the  fornicr  Imdy-wei^dit.  With  refereiiee  to  the  latter, 
children  cxhiliit  a  peculiar  relatidii.  .\fter  ~everc  and  iiKider.ite  attacks 
thcv  Idse  He-'h  in  the  felirile  stap'  with  cdiniiar.itively  (greater  rapidity, 
and  ill  jxeiH'ral  in  somewliat  (.Tcater  dcj.'ree  than  adults.  Imt  even  in 
the  W(ir-t  cases  thev  do  not  snlfer  the  extreme  loss  of  wei^rht  that 
dcenrs  in  the  latter.  While  the  srroatest  I'iss  df  weiirht  iiiit  I  have 
nliserved    in    severe   (^ses   in   adults  was   in   one    instmee  .']J   r)er  cent.. 


'ill 


.•^.•50 


ryriioin  ii:ver. 


!•  percent.  \v;i-  tlic  iiiaxirinmi  imchiimIi  n  il  in  cliiiilrcii  nndir  llic  .•ijrc 
(iC  twcKc-  _\r:ir-.  (  )ii  ilic  ciihcr  lianil,  llir  niinitniiiii  lo-s  oi'  wciirin 
(■I  rvc(l  ill  cliildiin  willi  -cvcrc  and  niipdci'alily  -(Acre  attacks  was 
'J.  '    per  ciiit.    Ill'  till-  li<iilv-\\rii:lit,  and    \\\v  lra~i    ainiiiiir  a<lult>   nndtr 


till'  sinic  cucnnislanii 


■  J   pir  cent. 


Tile  ircncnd  i'nIc.  tliat  iclap-o  arc  likely  tn  lie  the  nicirc  tVc(|iicnt 
tile  V(]nii;rer  the  patieTit,  i-  a|)|iliealilc  al-ii  to  cliildliudd.  'I'lic  tend,  ncv 
to  rcernde-ccncc-  and  rela|i~e--  i-,  witlinut  diiiil)t,  inure  pninunnced  at 
tliis  p.eiiod  (if  lite  iliaii  in  later  vear~.  Kxee|)tiiinal  cdiitniiiii'tnrv 
stati'incnl.--  are  lia-ed  eitlier  iipim  Uh<  -inall  >tati~tie~  or  upon  c.\ce|)tioiial 
cpidcinie-  and  cndcinio,  wliicli,  as  a  inatler  ot'  liict,  iiiav  ocea>ioiiallv 
C'xiiihit   a   deviation    from    the    rule. 

Thus,  in  lIunihiirL'.  in  the  year  1x^7,  altlimiL'li  1  observeil  not  aefually 
fewer  relap.ses  in  ehihlreii.  tlu'  |>er<'entiiLre  of  relap.ses  whs.  nevertheles.s 
(lisproportionately  lower  than  in  adnlts  ;  while  the  fiuMircs  for  the  year  l^WtJ, 
and  those  for  fourteen  years  at  l.eipsie,  aj:ree  with  those  that  I  lielieve  to 
rcprenent  the  usual  Mate  of  atiairs.  Ihere  i  'urreil  in  IlainhurL'  in  lc><^(J: 
Kelapses  in  adults  in  l:).4  per  cent.  :  in  children  in  lit..")  per  cei't.  :  in  Lei))- 
sic.  relapses  in  adults  in  12..'>  jmt  eenl.  :   in  children  in  11'.  1  jier  cent. 

It  is  interestiiiL'  that  even  in  relapses  in  ciiildren  the  jireponderant 
occurrence  in  the  female  ,se.v — which  almost  conslantlv  occurs  in  adults — 
is  at  times  distinetlv  exhihiled.  as  the  followiuL'  stalislic.-  of  Hand)ur<r  show: 


m 


i . 


m 


H.'l.-ipsrs,    1SS7  . 


H..ys  (.irN  l.ital. 

i:.  'i  |i.  r  iriit.         i;:!  s  |„  r  (.rit.  I!».  1  |iit  cut. 

11, :i         ••  l.-,o  \?.A 


A  fatal  termination  n't  the  disease  in  cliildlimul  is,  in  jfcnenil,  loss 
frequent  than  in  adnlts,  as  i»  almost  olivioiis  from  all  the  tiiregoing 
ohservations. 

All  estinialis  haped  upon  larire  statistics  confirm  this.  In  Unndinrp, 
for  instance,  the  mortality  anionir  ailults  in  the  year  IHXti  was  11..")  ])er 
cent.  ;  that  amoii|i  chihiren.  1  .'.'<  per  cent.  In  the  y  ar  |XH7  tiie  mortality 
amontr  children  was  (i.S  per  cent.,  with  an  avera;.'-e  mortality  later  in  life 
of  H.,H   |ier  cent. 

If  these  condition^  are  s.TUtmized  somewhat  more  carei'iilly,  the 
remarkalile  fad  will  Kecome  apparent  that  this  low  mortality  applies 
especially  to  childriMi  up  to  tlie  tenth  year.  From  the  tenth  to  the 
fourteenth  yitir  the  mortality  appro.ximates  that  of  the  niixt  ajre-period 
— irom    fifteen    to   twenty. 

A  tahiilatlon  of  the  related  fi2rures  from  Hamlmrjr  show=  :  Hetween  the 
second  ami  the  fifth  years,  a  mortalitv  of  4  per  cent.  :  sixth  and  the  tenth 
years,  (1.4  per  cent.;  eleventh  and  the  fourteenth  years,  s.  1  per  cent.; 
lifteonth  and   the  twentieth  years.  M.7   per  cent. 

In  infants,  and  in  ^eiier.il  during  the  tirst   two  years  of  life,  up  to 


r i/.v.r/Yo.vs'  /Y  sy^n"r()^/s  .\\n  cnrnsr:.  :v.\7 

the  third,  t\|il](>i(l  lever  ;i])|ie:irs  tii  lie  ili~liiietl_v  le.-~  euinmiiii  than  in 
later  ehildhuiMl.  It  i.~  tiiii',  as  has  heeii  seen,  tiiat  iiilra-uteriiie  traus- 
niis-iiiii  niav  take  plaee,  ahhuiiL'li  tlii>,  in  ivlaticm  tn  the  nuniher  uf 
t\[(h(iiii  iii(ilher>,  i-  to  be  eiinsiilere<l  as  tnn-l  exi'eptionul,  and  is  deiieiid- 
eiit  iiiMiii  <'ei'tain  dt'linite  ediidilinn-.  1  liave  ut'ien  seen  inliinl-  a  'd 
ehiidreii  between  one  and  Iwi  years  uld  remain  iieallhy,  in  sjtile  iit'eoii- 
stant  and  intimate  a--iieiatiiin  \vith  a  typlmid  mother.  A  tinal  npininn 
as  to  the  relative  lVe([neney  of  the  di-ea.-e  in  lh<'  earlie.-t  years  and  in 
later  <hiIdhood  i-,  natnralK  .  not    to   be   Ibrmed    from  ordinarv  statistii-al 


data.      T 


le  iiiiture  ot'  moderate  and  mild  attacks  in  infants  is  so  ciitireK 


nni'ertain   and    ill-d<'liii<'d    that    more   ea-es    are   eertainly   overlooked   at 
thi~   [ivriod   than    in    later  ehildhood. 

Coneliisi();is  hasril  U|ion  larL'e  statislies  iiiav  be  reai-licd  t'rntii  thp  rejxirts 
r)f  the  l^lizalielli  ami  ()Mcnliur:_'  (liildreii's  Iiiis|pitaU  ol'  S:.  I'elersbiir'.'. 
In  the  forinei-  lliero  were,  t'roin  the  vear  l^ttto  IMMi,  il.jOt  cases  ot"  tvphoid 


f. 


ever  ainoiiLT  .,.i_'..,i 


0  chil.lrcii  Ircaled   in   the  disiiensarv.      These  eases  are 


divi.-ilile  accDnlinLT  to  aire  as  tiillow- 


If.  M.iiith?  f.-l  MIcntlis 


Over  !'iv<'  V''P.rs. 


'J— ((.■Ji;  |HT.t.    V>     n.'.ili  |i,.r<t.    17:;^   t  '.It  [.  r  .t     llsl- 


it.  isdi;    :,i. 


I-ft. 


In  the  (lUtpatient  service  iil'  H  Micht'uss  at  the  (  )l(leiilnirLr  <'liildre:rs 
llosjiital  there  were,  a'uonu'  77.<lT'>  .~ick  chihiren.  lit"  with  tvphoid  t'ever, 
of  the  t'ollowinir  au'es  : 


1  r,  MmtiKis,  r,  rj  M.inllis.  1-:  V.^ar.'!. 


:-r.  Y.'urs 


Over  six  vtMir?. 


L'— ll.:;i  l»-r  .t.     .')     (I,77|"r.i,     11     -J.  10  |i,  r  ri.     L'l',     :;.'.'.i  (..r  ct.     41:;— i;:;.S  p.r  it. 
Ollivier'    had   aiiion^-   (ill    ca^cs   of    typiioid    t'cvcr   in    children   imlv    :'. 


under  the  a^.'  ot    two  vears 


.M 


v  own   ■>   iiatients   were    nnie   an 


1   eh 


months  and  n 


ne  and  tliree-ipiarter  years  old  respectively. 


Tile  clinical  statements  that  have  hitherto  been  made  with  retrard  to 
typhoid  fever  in  iid'an;-  are  ba~ed  especially  npon  severe  « i  ll-dcvcloped 
ea-is.  .\l-o.  my  •">  ca-es  of  that  character,  the  onlv  certain  ones  that 
I  havi'  -een,  piir-iie<l  ,a  severe  eoiir~e.  I  lerminatintr  fatallv.  Mod- 
erately ~evere  and  mild  I'ases  have  been  re|iortcd  lint  c\ee|)tionallv. 
.VmoiiLT  tlie-<'  belong:-;  the  Well-known  ob-ervation  of  (lerhardt-  of  a 
e;i:-e  ot'  typhoid  liver  in  a  i-hild  three  weeks  old.  jirobablv  infected 
within   the  iitern-   from   the  mother. 


Tlr 


.mnmu-  ol    the   att.-n 


can  but  nirelv  be  determined 


typhoid 


ievr  in    vonnLT  children 


even  m  Well-marUed    ca-es,  prohalilv  even 


less  commonly  than  during  the  -iib<e(|nent   years  of  life.      Onlv  eve  p- 


IliTtnf'K  '/.  K  '/'■•r/;rim/Ji  .   IM.  ii.      In    iliis  ! k  tin- I'lirli.r   lili  raturc  .if  tvplicij 


fever  in  iiifaiirv  li;i>  ln'i'ii  curifnUv  ci.Ui'clt'ii. 


ii 


:vS^n 


h 


P\if 


;):;.s 


lyrii'iiit  irvi.i:. 


liiiiKillv  ill   \iiiiii;:   cliildfcii   iliii'-   the  ili-c  lie:.)-   1  ■  -ct    ill   aliniptiv 

and   tlic   IcNcr  \^l   ri-c   i':i|iiill\.      \\  licii   ii    li.      nciii   I     -IMi'  1(1  iili-irw 
tlic    iiiilial    .-ta:;r,   ilic   I'lirw   Liiin'rallv    \\a~    >l  •,   i  •  l.cd    ,~(iiiu'\\  liat 


i'a\  ..I  [111-  .liMil.-i- 


sliiirtriii'il,  a<  ill  <  .,'rliai'dr~  ca-f.  Al-n  tiic  ta-tiLiinin.  and  wiili  it  the 
ciitirr  rdiriir  |Mriiid.  a|>|i(  ar-  I'l  ln'  LiriicralK  of  rclati\"(  1\  -li^rt  (liiralimi, 
alilmuirli   cxrciitinnal  ca-i  -  iia\(     lircii  iiliMT\cd  tiiat  wrrr   |initr:R'tf(l  lor 


|i;iv  .'f  11m-  ills.  11^ 


ll,     .1 

as  liiiiLT  ;i-    t\viiit\'--c\  lii  and  cmh    tliii'l\-'inr  da\-  lifiorc   drrcrvc-c'iicc 
(MTuiTid  ( I'"iiatii\v ').      It    i-  iiiiIcwiiMliy  tlial    in    -cv  en   ra-c- d'  (yi'li'iid 

'   |-,-;7.-v.,;i.,../    ,/''..;•  .1, ■;,/,■    I  ,ii,-l.t  i,„,^kr„  „  l,!i.  ,' .  „    i  ,„    h ,  iid.  s„l  tf  r .      Tninslatcl   into 
(IrniKiri   fr..Mi  thr  -..niid    Kii^.-iuii  fiiiti.in,    Viriii;a,    l^'.iT. 


*^^  i.« 


r  i/.7.r/7o.\w  i\  sy.Mi'TiiMs  a\j>  <(ifi:si:. 


;;:'.9 


fcvcr  ill  infiiiiiv  tlii  t<  ni|Mr;itiirf  i-  (jiiii.  \<\'j,\\  at  the  i'a-iijriiim,  in  jr*-'"- 
cral  liitriiir  tiiaii  (hiriiii.'  tin'  -iicccfdiiitr  ycai-.  did  liir  t('rn|irratiii'<-i'iirv(> 
i<  likriv  to  rc^cinliic  liiat  nl'  iciiiitti'iit  cciiiliiiiicil  ti'Vcr.  In  the  |)i'tio(l 
of  (ii'l'(i-\'c-ccnri'  the  l\|ii-  ot'  ~t(i'|i  ciwvi'S  nut  rafrly  inai\fs  it-i'lf  niani- 
li-t  al-ii  in  inl'aiii-.  A-  an  iilii-traliuii.  I  |irc-vnt  tile  cnrvc  iVoni  a  <'inl<l 
our  ami  tln'(t'-i|nan<i'  Mar-  I'ld  under  niv  can'  ( l''i.Lr.  •'•>).  mid  tmo  Inun 
a  lilllc  patiiiit  III'   I'ilalnw'-  (  l''ij_r.  .'Micii^ht  incmtli- eld. 

The  |inl-c  i-.  a-  wmdd  \iv  antici|ialc<l.  rcniafl\al)l_v  frc(|ncnt  and 
vaiial>lc  in  ca-c-i.!'  iy|iii(iid  li'Vir  in  intinn-y,  wiilmnt  llic  nniniiif  nf 
|iiil-(-iicat-  liciiiL'  in  il-<'lt'  I't'  (-|i(iial  |ir(i;^ii(i-iir  -i^niticancr.  I'aiiarj^r- 
niiiit  lit'  tile  -|i]('ii  i-  i^cnnallv  ,  allliMnL;li  in't  <'iin-lanll\',  dcni(in-tral)i<' ; 
lint,  (in  a<Tiiiinl  nl'  tlic  rici|iirncv  nt'  ii-  iicc'iii-"cniT  in  (■(inncc-liun  willi 
all  |iii— ililc  ciinditiiiii-  "InrinLT  'ai'lv  cliildlnMid.  it  i-  in  it-clt'nl'  niMrli  !<•-- 
dia^nii-tic  iiniiiirtaiiir  than  in  latri- year-.  llu-cnla'  appiar  to  liciicncr- 
ally  few   in   niniilxr.  and   air  oi't-ricf  wholly  al>-cnt   in   yimn:;  cliildnii 

tlian  in  oldrr  one-.      In  one  of  my  ca-i In  a  I'liild  eleven  niontli~  old — - 

wliicli  wa-  under  (Tniiial  oli-er\ati.iii  from  flie.  \cry  Im  Liiiinini.''  nniil  its 
liital  terminalion,  and  \\a-  e\;'.iiiir,ed  anatomieallv  al'ter  death,  ro-enla' 
Were  at  no  time  deiiion-lralile.  Mxeeplionally,  liowever,  tliev  have  lieeii 
foimd  in  LTi'i'at  |irofn,-ioii.  a-,  fir  iii-tan<'e,  in  ( !<'rliardt'-  ea-e. 

'i'liin,  walerv  -tool-  appear  to  lie  (piite  fre(|nent — more  eon-tantiv  .--o 
than  ill  older  children.  The  daily  nnnilier  ol'  -to<pls  is  at  the  -ame  time 
eoiiiparalivelv  -mall,  and  tlii-  fiet  niav  In'  a  i^iiide  in  the  dilVerenliation 
from  other  eondition-  of  earlv  childhood  which  are  atteiide<l  with  diar- 
rhea.     'l"he  nieteori-m  i-  -aid  hy  alnio-t  all  ol)-i'r\-ers  to  lie  -licht.      One 

ol'  my  ca-c- — in  a  child  eiLiht   nionlhs  old — in  which  r< \erv  eii-neil,  at 

one  time  throiiirhoiit  the  tntire  I'oiir-e  ot'  the  di-ea.-e  (.'xliiliitcd  distention 
of  the  alidoiiien. 

X'omitiiii;  is  particularly  fre(|iient  in  the  initial  -tap'  iind  at  its 
incejition.  Al-o,  dnrini:  the  further  coiir-i'  ot'  tin  di-ea-e  it  is  ot'icii 
repiaied.  Fn  a-sociatioii  with  the  ri;:idity  of  the  neck  ami  hack,  which 
i>  not  rarely  pre-ent  from  the  lieiriimini:  of  the  fe\  er,  the  cr\iim',  :ind  tho 
twitehiiiL:,  iiicrea>iih_'-  to  tin-  point  of  coin  iil-ion-,  it  is  well  (•alciiiate<l  to 
cNcile  -ii-pii  ion  of  inciiinLdti-,  \'  lii<  h  i<  the  di-easc  iiio-t  fre(|uentlv  con- 

I' de<lwitli   typhoid   fever    in  early  ihildhood.       With    thi'  ])roL;res-  of 

the  fever,  and  at  the  fa-tii:iiiiii,  tlie-e  -yiii|itoin-  n-nally  .-ulp>ide,  |o  l.o 
n'lplaced  liy  more  or  h  --  marki  il  -tnpor  and  sopor. 

lironehitis  aj.pears  in  -eneral  to  he  mild  in  intiint^.  while  lolmlar 
piieuinonia  is  ]iarticii]arly  fn  (jia  nt,  .iiid  i-  one  oi'  ihe  coininoii  direci, 
eaii-e-   o|'  death. 

'I  lie  dnraiion  and  inotruo-i-  of  weli-markid  typhoid   fever  in  infants 


>y^ 


llil 


W: 


!i 


1  'r 


W' 


;;  11 1 


ryriinii,  <  i  vi:i: 


ari'  <li:-lini'llv  iinliivni-alilr  in  ((iniiiiiri-iiii  willi  iIkp-c  hC  llic  MicciTillnir 
M':ir-.  and  .•irc  tlic  iri'nxi  r.  ;i|i|i;ii'<rill\ ,  tlic  \  iiiitii:i'i'  llir  iliild.  M  irl'aii  ' 
c.-tiiiialc-  the  iiiii|'I:ilil\  in  i:irl\  cliilillMH  .d  al  "I'l  |i(rc(iil.  In  adlilinn 
to  lir(in<-liM|ini  unmnia  and  -cvrrc  tii\iiiiia.  wliidi  arc  liv  far  tlic  niii~t 
t'rci|n(  nl  can-c-  "\'  di'alii.  perioral  inn  nf  i  Lc  Imuij  i  I  )|-c\vit  )  and  nlccra- 
tiun  111'  tile  lai\  n\  I  I -c\\  \  I  c\ci'|)tionalK  act  a^  ilii-ict  can-c-  ct'  licalii, 
( \cii  ill  llic  viiiniLic-l  ciiijilrcn. 

Typhoid  Fever  in  l^tcr  Life. —  A-  early  a~  liic  tl.riicili  year  cif 
litl'  the  -liLrliter  -ii-ee|ii  iliilil  \  III  llii'  di-ea-i  iieedine--  a|i|iaient.  The 
iiredi~|"i-lti(in  ,-iill  I'liilhir  diniini-he-  alter  tlie  tll'lielii  \ear.  -o  that 
t\  iilinid  I'ever  in  nld    aLie    ina\    n  alls    he  d<--itriiatid  a-  a  rai'<-  (iceiirr<  nee. 

AniDiiL' •>■>"•>  |■a^e^  dl'  i\]ihel.|  lever  nli^ervril  al  Leipsic- ami  I  lanihiirL'.  I 
leiinil   177  hilweeii    I'Miy  and  lil'lv  year-  el'  aL:<- :  41    lielueeii  lilty  anil  >i.\ly  ; 

II  heiueen  >i\i\  and  >eveiny:  and  ■>  e\  er  .-evenly.  'I'liere  were  1  ^<^.') 
lielueell    llle    au'e-    nf   lilleea    and    luenl\-ti\e    yiars.    iiowiver. 

The  inlhieiiee  i.l'  later  lili'  wllh  I'erereiiie  I.I  the  eiiiir-e  aiul  'ho 
])niLriiii-i-  111'  llle  di-ia-e  i-  lAiieihiiirly  nnl'av  nrahle.  A-  early  a-  the 
M'eiilid  half  111'  ihe  liiiirlh  deeade  ihe  di-ea-e  in  it-  ;^cneral  eniir>e.  <ir  in 
i-elatimi  til  -|ieeial  I'lalnri-.  i-  likely  In  a  — nine  a  -erinii-  and  even  an 
al.anniiiir  ehai'aeier.  A!".\e  ihe  Ini'tieih  \ear  the  amrlalilv  increases 
ciKirniiiii-K  .  -II  llial  in  llie  \i:ir-  lieiwieii  lil'u  and  -i\t\  it  rcai'hcs 
I'riiiii    lliree    In    lisc    liine-    that    IuUmiii    liliei  ii    ami    iwciily -live. 

The  iiiiirlalilv  in  llanihurL'-  in  l>^M'i  1>>>7  \\:i>.  in  the  !ii:e-|ieriiiii  rrnni 
twcntv-oiic  til  i\\eiii\-tive.  7.7  pel-  leiil.  :  l\M'iil\  -ix  In  tliiriy,  12.:i  jicr  cent. ; 
tliiriN -line  to  lliiri\-li\e,  II. .i  per  I'eiii.  ;  thiii\-i\  In  inrty.  11.!'  jicr  cent.  ; 
liirlv-one  to  I'nrlv-live.  l.''..^  per  cent.  ;  l'.irly->i.\  in  lil'ly,  -It'i.  I  percent.;  fil'ty- 
onc  111  iil'ly-livi'.  -'■'<  per  nnl.  :    tiri\->ix  In  >i.\ty.  -'17. -'i  per  eeiil. 

The  -iati>lic-  111'  the  clinic  at  I.eip-ic  (  IS'^ll  IMt:^.  witli,  it  is  true, 
a  hiL'her  avcrairc  iiinrlalits.  di-cln-c  .-iiiiilar  relatinns.  The  ninrlalitv  was, 
in  llic  aL'c-peiiiid  t'l'iMM  IwcnlN  ti  t\\  nlx-liiur.  \'-\>  per  ceiil.  ;  twciitv-llve 
In  tuenlv-niiic,  I'J  per  eenl,  :  liiirly  t(i  ihirty-liiur.  l."i  percent.;  tlnrty-tive 
In  ihirtv-nini .  ■_'"-. ^1   jur  leiil.  ;    I'nrtv  to  I'nrtv-l'nur.  2'.'.'-'   per  cent.  ;  I'mly-tive 

III  l'nrl\ -nine.  .'1 1   ]icr  eeiil.  ;    lii'l\'  In  liri\-nine.  4U  per  cent. 

In  the  ni.iinril V  111'  ca-c-  in  -cnilc  iniiividual-  the  lici^innin:;-  nl"  the 
allael<  and  the  a-ccni  nt'  i  he  I'cvei-  .ire  i.i-radiial.  W  hen  the  lieeinniiiLr  id' 
the  lilii'ile  perinil  i-  allendcd  w  iili  cliillv  -in-atinii-,  liie-c  are  likely  to 
i-on-i>t  jreiii  iall\-  in  re]iealcd  chilliiie— .  only  ipiilc  rarely  eoiilincil  to  a 
-inu'lc  chill  :   in    the   latter  case   the  conr-c  is  ii-iially  aluiornial    in  other 

re-|)ecls  al-o. 

The  I'lirlher  e\-olntinn  ill'  the  entire  clinical  jiictnre  i-;  marked  l>v 
the    evidences  ol'   le--cheil  |)n\Mr-  of   re-i-tailce  of  the  -cnilc  iiody    to  the 

I  'I'rn'ii:  ,lr^  ^u(ihulii-s  ,/,■  I' r.if.i „,••.  Is',i7_  Till-  wrk  li.ntairis  iil-n  mniRTuu.s 
l)il'l''-'j;rapliii'   nl'iTciici--.    e-|.i-.i:illy    {••   n-e.nt    Kn  mli    puMiralinn.-. 


m\ 


ri/.7.i/7o\v  IS  .sr.i//'/o.i/s-   i.W)  cornsi:. 


•■vn 


iiitoNicutioii.  Ill  iiKirkfil  rdiiinist  to  llic  |i(iiiM!  ol'  \  milli,  llii~  lnucifd 
i't-i-t:mcc  i-  i'ni|iu  litis  ixliiUilcil  in  tlic  ^'iiicral  ciiinlitidii,  ami  particii- 
larlv  ill  tlic  (••iiidilii'ii  nf  tlic  iii'i'vous  s_\>t<iii.  (ii'cat  ])i'()-tratiiiii  is 
in-c-i'iit  t'l'iiii  llir  l)(i:iiiiiiiii:.  AiiiniiLr  the  -]irciai  iicrvoii-  ili-turliaiiccs, 
-viiipliiiii- 111' I'Nc'il,  iiiciil  arc  miii-li  lt>s  t'ir((iiciil  than  tlm-c  i>t' (l(|ir(->inii. 
Tlif  ]iaticiits  licciiiiic  -tn|iiil  at  an  early  ]"  riuil.  Not  rarely  they  are 
linitiilincllv  sni)oru-e  or  ilee|ii\-  edinalci-e  at  the  lieLrinniii^'  ot  the  -eeiilid 
week.  Al  the  -aiiie  I iiiie.  or  a  little  later,  tri'eat  a-lheiiia,  aeeiiiii|ianie(l 
hv  tiiiuipr.  -iili-iilliis  teiiiiiiinm,  atul  tldetitatioii.  sets  in.  The  patients 
nniler  >lleli  eirellin-tanee^  are  re-lle-s,  iitleli  whiilly  >iee|ile-s,  liut  jreiK'r- 
allv  without  severe  ijeliriiiin.  Pallid,  with  relaxed  I'eatiire-  and  hall- 
(i|iell  eves,  liilirililirili'_'-  t'eehlv  to  thelil-ehc-,  tliev  oeeii|iy  a  I'elaxi'd  dorsal 
deeiiiiitns,  the  pietiirt'  ot'  the  adyiiaiuie  fehiile  course  of'  earlier  writer.-. 
This  character  ot'  relaxation  or  advnaniia  i-  exliihited  in  the  cmir.-e 
ot'  tlie  t'atal  ea-e<,  as  well  .1-  in  that  of  the  severe  cases  that  ceentiially 
teriiiiiiate  in  rc<'ovcrv.  'I'lie  latter  are  i^enerally  iiniisiially  Ioiil"' in  dura- 
tion, not  alone  with  ret'creiice  t  >  ;lie  i'ehrile  -taire,  lint  in  coni])arati\  elv 
still  irrcaler  deL''ree  with  ret'creliec  to  the  ^tajre  of  convalesecliec.  'file 
fever,  under  -iieli  eirciiiii^taiice-,  does  not,  in  the  iiiajoritv  of  ca-es, 
attain  the  same  heiirht  as  i.-  likely  to  he  attained  in  -evere  ea-cs  dnrin<j 
adolesceiK'c.  On  the  eoiitfary,  the  tein])craliire-eiirve  i-  very  fre(|iiently 
oli-erved  to  pursue  a  relatively  low  level,  jll>t  as  the  afilifilc  case- of 
iiio-t  -evcre  coiM>e,  a-  was  |)revioii-ly  inentioncd.  princi|ially  occur  in 
deliilitated  senile  individuals.  In  addition,  the  lorin  ot'  the  ciir\e  is 
far  more  t"re(|iiehlly  irreu'idar,  niarkr'dly  remittent,  at  tiiius  interniittcnt, 
and  marked  hy  .atlai'k-  ot'triic  or  fal-e  eolla]>-e  than  occur-  at  aiiv  other 
time  in  lit'e.  Ot'teii  the  -ta^-c-  o|'  the  di-ea-e  are  im|(erfectl\  if  at  all, 
marked  In  the  tcin|)eratiiri'-ciirve.  ^o  that  neither  the  -te|i-like  a-<'ent  at 
the  licLi'iiiiiinLr,  nor  the  contiiiiiaiiec  ot'  a  eon-ideralilc  a\'eraire  (  livation 
ot  teni|ieratiire  in  the  -evere-t  periocl  ot'  the  diseas',  nor  \'ct  a  marked 
staire  ot'  -tee])  curves,  is  procnt.  Not  a  few  ca^'s,  on  the  ci>iitra!'\-, 
piir-iie  -o  anomalous  a  cour-e  that  the  ti^nn  ot'  tli  •  ciirxc  furnishes 
II"  diaL;iio-lie  iiiliirmalion  whatever,  lint  rather  mav  lead  to  iiicnrrect 
coni'lii-ioii-. 

I  lie  -low  iu;^- of  the  piil-c,  which  i-  -o  t'r.(|iicnt  .-iiid  eharai'teri-lic  in 
yoiiii^'-  vju-iiroii-  individual-,  is  extremely  rare  in  tin  aL''<'d,  and  in  niv 
experience  aliiio-t  only  occurs  wIk  n  the  -eiiile  character  ot'  the  dl-caso 
i-  al-o  li --  mark-'d  in  other  rc-pect-.  'I'lic  jiiil-c  in  eldeilv  iiiili\  idiials 
i-.  on  the  contrary,  usually  fiv,|ii,  nt  from  the  iiit-el — on  the  a\ cimi.'-c 
more  so  than  the  lu'iLiht  of  the  teiii|ieratiirc  warrant-;  and,  what  is 
indicative  especially  of  a   marked  toxic  etfeet   upon   the   heart  ami  the 


1..-C 


{<U;t 


■1,,:. 


■%'.-^ 


jisli^- 


342 


TYi'iKiin  ii:vi:i:. 


vaxiiiidtiir-,  i>  till'  Hid  ili:it  the  j)iil-c  i>  <';iily  i.t'  Inw  tcii-ion,  irn  L'ular, 
and,  when  artcrio-rli  ro-i~  i-  not  ]ircMiii,  i-  -<it't,  Imi  -clilniii  ilicrniir. 

'Ilic  cardiac  \vcakiic.->  tliat  -n  early  a|i|i(al>  in  the  tlircLMnniid  is  alxi 
rc^jxiii-ililc  ill  <(iii~iiici'alilc  dcLM'cc  f'nr  tlic  >tatc  nt  tlic  i(-|)iiat(ir\  nri.Mii-. 
On  accdiiiit  (i('  liic  iiii|iaircd  |ii-n|Md-ivc  jMiwcr  t<i'  tlic  riL'lil  side  nl'  tlic 
licart,  tlic  I\|iliuid  linincliili-  early  altaiiiT-  a  cnii-iileralplc  (Icltcc  of 
intciisitv  and  extent.  Tlic  a--(iciate<l  livpci-lalic  ciinLie-tinn  wliieli,  in 
nipai'i-cin  uiili  ii>  t'rc(|iicncy  in  early  lite,  xcry  eipmiiHinly  uccnr-  in 
Iderlv  |iers(iii-.  i-  de|iendiiit  ii|i(in  tlic  -anie  i  an-e.  Tlie  <in-et  nf  tlii- 
liviMi-tatie  e(inc;e-tiiin  ccin-litntes  one  ot'  tlie  iiidi<'atiiin- ct'  a  fatal  oiit- 
ennie  in  senile  tvplinid  t'ever.  Tlie  (iccnrrciice  (if  l)i-iineli<i|ineiinioiiia  is 
as-iicialed  with  the  |irevalenee  of  iinincliitis,  and  nceiir-  with  alinn^t 
icjiial  tr(M|nenev  in  cliildliiMi<l  and  in  later  lite.  |-",lilerly  |iatienls  -nlVer- 
iiiLT  iniin  tv])h(jid  fever  arc  nut  le-s  fi-ciniciitly  attai'kcd  liy  crcin]Miiis 
pneiiinoiiia  than  vdiinirer  ]>atieiits,  while  jineniiionia  due  to  stre|)tiic(ieei 
aiiiiears  to  ine  to  occur  niorc  frecjUcntly  in  the  furniei'.  The  c'reater 
tendeiirv  to  Lnmixrene  anc'  ili-cess  in  as-oeiation  with  |ineunioiiia  in  older 
])atients  is  noteworth\ .  That  the  cliroiiie  lironeliial  ami  [nilnioiiary  aifee- 
tions  ot'tcn  existin;:  in  old  |ierson>  lictiu'c  the  develo|inient  oi'  the  t\  plioid 
fever  jrivc  to  this  di-ease  a  Lrnivc  a-|icct  needs  scarcely  lie  opeeially 
pointed  out. 

Tlie  anatomic  and  clinical  manifestation-  on  the  part  of  tiie  intes- 
tinal canal  exhihit  im  radical  ditl'erence-  from  tlio-e  in  other  adults.  This 
is  ajiplicalilc  espeeiallv  to  the  nnmlicr  and  the  character  ot"  tlic  stcMils. 
Tlie  nieteorism,  which  not  rarely  is  tuarketl,  sets  in  relatively  early.  In 
('onli~adistiiiction  to  the  conditions  in  childhood,  clderlv  individuals — 
and  this  ajiplics  especially  to  the  jieriiHl  hctweeii  the  tliirty-liftli  and  the 

fortieth  v&ir: exliilut  a  somewhat  irreater  teiideni'y  to  intestinal  hemnr- 

rha<r<\  Elderlv  persons  also  snceiinil)  more  readily  to  this  accident. 
Even  sliyht  lieniorrhaL^es  that  would  exert  scarcely  any,  or  hut  a  transi- 
ton-,  inflnenee  upon  vnimirer  per-on<.  constitnte  a  source  of  considerahlo 
dantrer  for  older  oik-.  Perforative  periloniti-  appears  t<i  me  to  lie,  on 
till'  whole,  liv  no  mean<  more  fi'e(|U(>nt  in  advanced  life,  hut  rather  loss 
common  than  duriiiir  adole-ci'iicc. 

TUo  increased  dillieiilty  in  the  diairiKisis  of  lyjihoid  fcxcr  in  elderly 
persons,  in  <  on-ei|iii'nce  of  the  varialiilitv  and  irrcL'ularily  in  the  fever- 
eiirve.  is  still  I'lirther  aiiirmented  liy  the  -tatc  of  tip  -pleen  anil  the 
roseoho.  KnlarL'cmcnt  of  the  spleen  in  eld(>rly  persons  i-.  on  the  whole, 
di-tinctl\  lis-  common  than  at  other  periods  of  life.  In  none  o|  tlie-(> 
earlier  pi  nod-  have  I  oli-erved  t.ital  ali-enee  throui.dioiit  the  entire 
cour-c  of  the  di-ease  neariv  so  tVeuuenilv  as  duriiii::  ^'k'  1:''<'1'  pei'iods  ol 


r.i/.'M /7".v\  /.v  .sr.i//'/o.vv  .t-v/(  cornsK. 


343 


life.  Kx|i(ri('iicc  at  tlic  :uilip|(-y-tal)lc  :it1i>nU  :i<l(i(iiali'  cxiilaiiation 
I'lif  tlii-.  I'lif  iii\  nliiticiii  111'  llir  iii'irari  a— i«'i:ii((l  with  ailvaiucd  liti', 
aiit(ci<li'iit  (li^fusf  <it"  till'  >|)l(iii  and  it-  cait.-iilc,  cxtciisivi'  or  iniilti|)l(; 
cicati-icc-  n-iilliiiir  iVniii  iiil'arcts,  (liU'ii:-!'  (■i(iiiit<'tiv<'-li-siic  liyj>cr|ila.-ia, 
ami  |irii-|ilriiili  •  llncl.iiiiiij.f  ot'  tin-  i'a|)--iil('  arc  all  In  l)c  iiiciilii>iic<l  ojm'- 
cialK-  a-  I'actdi-  wliirli  ixiiiaiii  the  iiirr((|iicii(y  nf"  ^picnic  ('iilar^^ciiiciit. 
It'  llii>c  pn Mill  llic  i.ccuri-riicc  III'  cMlarirciiu'iit  of  tin  .-plccii  in  a  |)(ir- 
lidii  111'  llic  la-i  -.  lli;-  ililHriiilv  111  tin'  iliiiiini-tnitimi  cif  lln'  ciilarjiciiiriil, 
even  wiirii  il  iaI-I-,  i-  -till  t'lirllicr  iiirrca-nl  liy  ili-placciuriil-*  ami  adlu- 
>ii)tis,  il(|>rmliiit  iip.iii  di-ra-i'  at  an  larlicr  |Mri(id  in  litr,  wliirli  naturally 
arc  niiii'c  cnniniun  in  nldrr  imlivid"al>.  Al~ii,  tlic  rare  cases  in  wliicli, 
at  the  li;  itrlil  111'  llic  dix'isc,  I  have  iili~('r\cil  anatniiiically  entire  inex- 
Jilicalile  ali-enee  nf  cnlarL'enient  nf  tlic  >|)leeii,  i.eelllTcil  almiist  solely  ill 
elderlv  ]ier-iin-. 

Willie  the  t\phiiiil  ro-iohe  do  not,  in  luy  experieiiee.  oeeiir  li'ss  eoni- 
iiioidv  ill  aiKaneed  life,  the  eriiptioii  is,  on  tiie  whole,  less  jirol'iise,  and 
iii'tcn  extends  over  a  shortiT  period  of  time.  In  addition,  the  indi- 
vidual roseiila-  arc,  in  jrciieral,  stnallcr,  les-  hrifrht  in  color,  and  of 
shorter  duration — piculiarities  that  arc  apparently  associated  with  the 
senile  alterations  in  the  skin.  The  same  explanation  pmhaldy  also 
liolds  for  the  less  eoininun  apj)eanince  of  sndamina,  and,  eonver.-ely,  for 
the  <j;reatcr  tendency  to  hed— ores. 

Will  regard  to  the  cliaii;:es  in  the  kidneys,  tyjihoid  nephritis  apix-ars 
to  ino  to  lie  di-tinctly  le-s  frei|nent  ;  while  the  oceiirrenco  and  tiie 
svniptoinatolojjfv  ot  tehrilc  allininiimria  exliihit  no  ditferenees  from  those 
of  the  s;ime  eomlitioi.  at  other  times  of  life. 

With  reference  to  typhoid  fever  in  the  a{re<l  in  ireiienil,  it  slioiild  be 
emphasized  that  in  the  event  of  ri^'overy  it  has  the  mo>t  frcipiently,  of 
all  the  varieties,  a  lonji-dniwn-out  and  ]irotr:ieti'd  course.  Severe  eom- 
plieations  are  not  niimcroiis  or  diverse,  for  the  simple  reason  that  ajri'<l 
persons  alino-t  always  sneeiitnh  to  the  tirst  that  ap]>ears.  Of  the  s|>e<^ial» 
varieties  of  the  disca-e  |)revionsly  nientiiine<l,  the  hyperfiyretie  and  the 
hemorrhairi*'  funis  are  distinctly  le-s  common  in  later  life.  Tlie  ])re- 
ponderant  earlv  involvement  of  particular  orirans,  jxivinix  the  disease  a 
special  ehar;icter,  a])])ears  also  to  he  less  freipient.  Cases  that  could  he 
(le-iLrnateil  iie|)hrotvplioid,  nieninLrotyjtlioid,  or  picurotyphoid  h.wc  in 
my  'xperienee  hut  rarelv  occnrrnl  in  older  per-ous.  Pnenniotyplioid, 
however,  appear-  to  me  to  he  not  less  common  than  dnrin;;  adolescence. 
W  itii  reference  to  relapses  and  reerndescences,  it  is  noteworthy  that 
their  iVeipieiicy  dimini-lies  di-linctly  with  iiierea-intr  years,  hut  their 
pioixnosi-   i-  far  more  iri-ave  than   in  younirer  individuals.      'I'hat  deiith 


344 


TYI'll'ill,    i  IVIll. 


m 


m 


iicciii-  111  :i  ((iiiiiiaralisch    i:\\\\    |m  riMil    i-    in   rm    -iii:ill  ilcLMCf  iliic  In  \\w 

l(~-(n(ll      liniliK       1<  -i-lalicr.  Kill,    lllJ      lllr     wlllcl'     liallll,    (Icltll      llia\'      otilli 

occur  ill  clil.  rl\  iiidiviiliial-  alter  allacL-  «liicli  wi^rc  in  I  liciii-cl\  <s 
:i|p|iarciill\  iml  -c\cri-,  Iml  which  smic  c.t  iinii-iialK  liiii;_r-  iliiral  icni. 
The  iiii|in--i"ii  i-  'iaiihil  ihiil  -iich  |ial  icni-  arc  no  luni;cr  alih  lu  rc-i-l. 
'I  lie  illcoiii|ile|c.  liilM.  or  alilire\  ialeil  allaek- — liiiM  t\|ihiiii|  le\er,  aliul- 
ti\  e  l\  phdiil  fever,  etc. — i|i  mlii  le--  i.eciir-  al-ii  ill  aiKanecd  lite.  'I'lio 
exact  relation  it-  lVe(|neiie\  lie.-ir-  til  that  MiiriiiLr  earlier  |ieriii(l-  of  lite  is 
litikiH'W  11  t'l  tiic,  ami,  -'1  lar  a-  1  am  aware,  ha-  ti"i   \  ct   hceii  ileteriniiicil. 


^S 


m 


\{\i 


W 


IP 


RECRUDESCENCES  AND   RELAPSES. 

In  ca-c<  <:{'  iv|iliiiiil  t(\cr  ..|'  aii\'  \ariet\  or  cMiir-c  it  may  lia|i|)ell 
that  liefiire  the  mi-ct  .p|'  linal  eiiii\ale-eciice  there  ma_\  icciir.  witliciit 
:iii\  ntlur  ec|||.,;i|  ,,|-  \  i-ecral  di-ca-e.  mice  or  e\eM  -e\cral  tinier, 
I'clirilc  -late-  wlio-e  iiiiir-e  .mil  :i--oeiateil  |ilieihimeiia  ma\  mure  uv  le-s 
<'l(i-elv  rc-emlp|e  thii-ciif  the  |iriiiKir\'  feliriie  iicrini!.  'I'liev  are  (lc.~i^- 
liatcil.  t'lir  "l>viiiii^  riM-in-,  a-  rela|i-e-,  if  the  lir-t  iierind  nt'  the  di-casc 
is  -c|)arated  I'imiii  the  renewed  clcxatinii  i.f  tem]ieratiire  iiv  a  ci.mjpletilv 
at'ehrilc  intcr\al.  and  a-  reiaaide-ceiiee-.  it'  the  na-eciil  iicciii>  diirinj; 
the  pcridd  of  in\  i iliit inn.  licl'.ire  the  declining:  t('m[i('nitiiiv  has  cniii- 
jiictclx     returned    tn    the    n"rni,il. 

('liiiically  and  anatiiinicall\ ,  rel.i|i-es  and  rccriidc-ceiicc-  represent 
rccnrrciicc-.  in  innre  ur  le--  eiim|il(  le  dei.'rcc.  nl'  the  t\|)h(iid  innrKid 
JlfdCCSS.  As  In  the  (|llc-tinn  whether  tlie\-  are  In  lie  atlrilillled  t(» 
renewed  iiil'ectinii  nr  In  a  revisal  nl'  the  [irimaiy  |p|-nce--,  it  may  lie  -aid 
that  at  the  |ire-ent  lime  it  lia-  liccn  detlniti  ly  -citled  that  they  ari-e  in 
the  latter  inaimer.  I 'iidniil)ied!\',  their  dcMln|)incnt  i-  tn  lie  atti'iliulcd 
tn  the  rc-ciitranci'  iiitn  thi'  eiieiilatinii  nt  li\  iiiir  ty|ilinid-iiaeilli  which, 
after  llic'  |iriiiiar\  allach.  were  iel't  liehind  in  varinii-  nri;aii- ;  and  a— o- 
ciateil  with  till-  iimre  nr  le--  c'nm]i!ete  redevclnjimcnt  i<\'  the  Ine.il  and 
freiieral  t\|ilinid  !e-inn<  neciir-.  The  |iatieiit-  tiicn  auain  exhiliit  I'cver, 
(ifteii  in  a  tnn-i  cli;iraelcri-lic  manner,  with  re-cnlarLrcmeiit  nt'tlie  -|ileen, 
rn.-en|;c.  tiietenri-m.  and  diarrhea,  and.  in  I'atal  <-a-e-  in  which  |in-t- 
iiinrtem  cxainin.atinii-  are  made,  newly  d.'\eln|iei|  -|iecilii'  inie-tinal 
le-inii-.    (-|ieciill\-    ree.iii    ill  fi  1 1  rat  inn    nf    I'lyer"-    [latclic-.  are    fiimd    in 

addilinii     In    the    healed     le-inll-. 

A-  litili- nf  a   detinite   n.itiire  i-  .a-   yet    knnwn  with  rcl'erein-c   tn    the 

liiaimia'  in  which   the  t\|ilini(|  \  iru-    i-    relaiiied  and    tli 'Liaii-  lliat  arc 

(■-]ieciallv    In    lie    tiLcii    iiitn    cnn-iderat inn    in    tlii-    ennneetinii.    as    with 
rctrard  tn  the  nianiK  r  and  the  s|iecial    eniidilinii-    under  which  the  liacilli 


i:i:(  nri)i:s(i:Mi:s   \si>  i:i  i.M'shs. 


.•Jir> 


a;.Miii  L'':iiri  cntraiicr  inl"  lliv  1)Ii"m1.  I'ldlialily  llic  -|il((ii,  lop'llici-  willi 
tlir  l\rn|ili-u'laiiil~  .ilid  l"ili<-liiaini\\ .  aii>l  |ici--ilil_v  al-o  tlic  ;_Mll-l)lail(l(  r, 
jilav  an  iiii|Mpitaiit  /■'•/<   in  ilii-  i-(,iiiiifii.iM  ( -i  r  p.  'JnT  i. 

|-"niin  tlir  cMiir-c,  ami  i-|H(iall\    l\\i-  -.Aciily,  'if  ilir  |(riniar\   di-ca-c, 

t , lii-ioii  (.111  lir  (liawM  a-  {'>  till'  |iii.lialiilily  I'l'  tin-  ..ciiii'i-iiicc  of  a 

rclap-c.  A|p|)arrriily.  the  |)i((li-|Mi-iiinn  to  rdap-r  i-  cvi  ii  irnatcr  in 
tlic  niililcr  lliaii  in  llic  -cvirc  r  c  a-c-.  In  my  r\|irri(ncc.  unly  fmin  •_'•'> 
Id  ;;.".  |)ii-  ccnl.  ■■t'  rclap-i-  nci  nr  afirr  .-cvcic  |ii-iniary  attark>,  wliiir  all 
otiicr-  folli.w  MiiiiliTatc  and  mild  attack-.  It  i-  c|nit('  cunnnon  for 
alvpical  ca-c-  >A'  tv|iiioid   I'cvir — ilic  niild<-t.  alpiii'ti\<'.  or  ainliulatory  — 

to    lie    fo||o\vr<l    liv     -rvcl-r,    lonLT- tillUrd,  and   \V<  ll-drVclo|i((|     rcla|)-c~, 

so  cliararli'ii-tic  that  tin  |ircvion-ly  nnccrtain  diaL^im-i^  i^  lir-t  inadf 
]>o-itivr   1)V    tlicin   (-(■(■    l''iir.    o'i). 

( >iir  lA'i|i.-ii-  .-talistirs  r-liow  tliat  ol'  ■Jld  rfla|iscH,  ~'>  |kt  ctiit.  iMcurrfd  alUT 
motlenitf  aii<l  iiilld  altat-k.s.  Al.-o.  Zii'iii.-sfM  oIimtvi'iI  aiiioui;  10f<  rclaiisc.-', 
oiilv  '2X,  tluis  aliDUl  ont'-(|iiarttT,  iollowiiiL'  seven-  titlarks,  (iotli  arrivccl  at 
iiini'ilar   results.      That   this   rehitinii    may  he   altereil   at    times   in   .some  epi- 

ilemics  is  shown   hv  my  HamlnirL'  stati^ties.  ai nliiii:  tn  whieli  '_':!»)  relapses 

were  nliserveil  alter  severe,  ami  "JtiO  alter  mild,  primary  attacks. 

It  has  hern  .-erii  that  for  the  rceoirnition  of  a  relap-c  in  the  -trict 
spn.-c  (if  the  word  an  actual  afehrilr  period  nni-t  have  inters  (■nc<l  lictwcca 
the  tcrinination  of  the  primary  attack  and  the  l»  iriiiiiini:  of  the  .-I'condary 
elevation  of  temperature.  N'atnnilly,  this  interval  is  not  necessarily 
incasiircd  hv  davs.  I'ndonhtcdly,  from  twelve  to  twenty-fonr  hours 
niav  even  -nllicu.  and  iheret'orc  it  is  (piitc  obvious  that  there  cxi-ts  only 
a  irnulnal  tran-ition.  and  no  essential  ditl'ercnce  hctwcen  that  which  is 
dcsiirnated  a-  a  recrnde.-cence   and  that  which  i-  de-iL'tiatcd  as  a  relapse. 

The  time  that  ela|i-es  li<'lwecn  the  primary  attack  and  the  lieiriiiniiiiX 
of  the  relap-c  is  eNticnicIv  varialilc.  Xo  relation  lietween  the  duration 
of  tlii~  interval  and  the  character  and  severity  of  the  pri-nary  atta<'k 
can  In' denion-irali'd.  In  my  experience,  wliii'h  coincide-  with  that  of 
inosi  olt.-erver-.  the  lai'LTc-t  iiiimlicr  d'  rcl:ip-cs  occurs  lict'orc  the  fourteciitli 
to  ,-c\  riitceiith  d:i\-  .liter  the  |irimary  <letir\  c-cciice.  Within  tin-  limit 
the  duration  ol'  ihc  afelnile  period  i-  ipiitc  vaiiahlc  The  heirinninL'-  of 
the  rclap-e  is  likely  to  he  -omewhat  le-s  comiiiou  <liiriinr  the  iii>t  few 
afelirile  dav-,  while  after  the  third  or  the  timrth  day  the  onset  is 
oliserved  almo-t  a>  iVe(|iientlv  as  on  the  -nli.-eipient  days.  .Miout  h'  to 
I'J  per  cent,  of  rel.ip-e^  licLrin  afici-  the  sexcnteeiilh  day.  anil  tho 
majoritv  .it'  the-e  occur  hefore  the  thirtieth  day.  I'^vcn  after  this 
intiTval,  however,  relajises  may  exceptionally  occiii-.  'I  he  lon!_rest 
time  that  I  have  ohxTved  to  ela|ise  lieliire  the  on-et  ot"  llic  relapse 
was    til'i\ -three   davs. 


34(j 


ryi-ii'iii)  I  i:\i  i;. 


il 


i 


^Mt 


( I 


I'litnii-  <  >.ii-iil(iin_'  till'  iliniial  -\  mi[iIoiii~  n|'  rcl:i|i~i-  ;iii<l  n-ci  inIi  — 
<'tii''<-  in  <|. nil,  it  iiia\  lie  -i.iird  in  ;_niii ml  llial  willi  !••  i-aid  in  cnnr-'', 
<laraiii>n.  anil  -cs.  ril\,  llir\  \ar\  alij]"-!  a-  tn'icli  a-  (|..c-  ilir  |ii-inia.  >■ 
atlark.  li  li.i-  Imih  -I  in  llial  llir  laltir  i-.  in  tjir  \av^c  nKijciril\  nl' 
ca-i-,  nnalliniitd  wiili  -li^lii  or  im  inanili-Ialidii-  iluiiriL'-  iIh-  |pi  I'idil  ..f 
iiH'iiliatii'ii.  Willi  till-  la' I  ii.nr-|iMnil-  llic  iniiiiiinn  \  ii  w  tliiil  llic 
at' lirili  inlii\al  up  I"  llic  In  i^iiiiiin'j- nl'  the  in  lap-r  i-  ^nncialU  iVcc  tVnlil 
:iii\  -N  ni|iliiiii-  thai  ini'^lil  |M.iii'  i<>  ilic  ini]M  inline''  ri.n<liliun.  I'm  llii-, 
lie  i\\(\  1  I',  ihii'r  arc  -uii;.-  i\ii|)i  ii.ii-  wliidi  arc   i>l    dia;:!!''-!  ic  iiii|iiirlalH'i'. 

Allcnliiiii  \\a-  callcil  -nnic  liiiicaL'^ii  liv  <  li  ilianll  '  lu  one  tad  lliat 
1  call  c(iiii|ilci(  ly  \crir\-  —  ihat  i-,  tlic  inci'in|iiclc  ^iil.-iilciicc  iil'  llu! 
I'lilaru'^ciiiciii  1. 1'  llic  ~|ilccii  alter  tlic  |iriinaiy  (lct'cr\"c-ciiicc.  Si  Icniir  as 
the  ciilaiLiciiiciit  111'  the  -plccii  lia~  ii"t  ili~a|i|M'ar<'ii.  the  |ili\-iciaii  i-  not 
relie\c(l  I'l'iiin  anxieiv  with  ii  v'ard  In  a  nlajiM'.  In  the  ii\  crwheliniii;; 
iiiaji'iily  111'  -iich  ca-e-  he  w  ill.  mi  the  cnntrary,  iili-<i'\  c  it-  iiceiineiicc.  1 
lielievc  al-ii.  Iiiiwcvcr,  that  eard'ul  altcntinii  -Imiilil  he  ei\cii  tn  the  -tatc 
lit'  the  teinpcratiiie  ami  the  ]iiil-e  iliiriiiLr  eiiiivalc-ceiiee  with  reiranl  to 
the  -aiiie  piiiiil.  I  lia\e  p' linteil  uiit  that  after  all  -e\eie  and  iiiudfi'- 
atei\  -cvei'e,  nut  rai'clv  at'ter  eveii  appareiitlv  mild.  CISC-,  the  Ifiiipera- 
tiiic  t'llls  ^uiiii  at'ter  det'crve-ccnci,  nut  mily  tn  the  previiiii>!_''  nnrnial 
le\ el  I'll!'  the  individual,  lull  fiir  a  certain  time  c\cn  lulnw  llii-.  \\  cll- 
liiarheil  eaM~  in  wiiicli.  alter  deti  r\e-eeiicc,  the  ciiiiise  lit'  the  <'iirve 
due-  Iiiil  litiiillie  >lll)Miirili:il  are  Ilnl  tn  lie  cnn-idiled  a-  enliehided,  lillt, 
on  the  eiiiitrarx .  the  ]in~-iliilitv  nt'  an  iiiipendini.'  relap-e  siiould  he 
.«tl<pe<ted  :  and  the  -ii~pieinn  -limild  lie  ^tI•llnJXl'l•  it'  the  tein])('ratiire  at 
tlii-  luu   level  exhiliits  caii-ele--,  aliniiriiially  niarkeil,  daily  tllictiiatiiiiis. 

riii-  ])niiiivnitnrv  chanicter  nt'  the  ternjHratiirc  in  the  face  of  an 
iiii]iendiiiL:  relap-e  i-  aliiui-t  alwavs  a-Mn-iate<l  with  a  -iinilar  jxTuliaiity 
lit'  the  ])iil-e.  It  i-  likelv  under  >iieli  cireiiinstance-.  in  <pite  nt"  per- 
fectly ipiiet.  earcfiil  liehavinr  on  \\\r  part  nf  the  jiatient.  to  exhihit,  iu 
addition  to  rclatixcly  irreat  freipiency.  innre  freijiunt  and  iiiiii>iially 
marked    tlnctnatinii-. 

If  a  lai'ee  nninlier  nt'  curves  fmni  ca.-es  of  r(la]i>e  are  aiialy/cd,  it 
will  he  oh-cncd — as  ap|iea;>  to  nie  not  to  iiave  liceii  r-iitlieiciilly  t'lnplia- 
>i/ed  heretofnn — that  in  the  majority  tlii-  peculiar  preiiiniiitnry  char- 
acter 1)1'  the  piil-e-ciir\e,  which  i-^  aiialnirnu<  in  that  nf  the  ti  iiiperatiirc- 
ciirve,  i-  pre-eiit  in  more  or  Ic-s  di-tiiictly  marked  deLrrcc.  I'.veii 
the  ca-es  in  which,  in  spite  of  a  -uhnornial  I'our-e  of  the  temperature 
after  the  priinarv  deferve-ceiiee.  rela|)-e  occur-,  the  iiii.-et  i-  fre(|Hently 
preceded    liv  the  important    diai.Mio-tic  character  of  the  piil>e  mentioned. 


/.'/.'  /; I  I'lyi  i.M  IS   I  \i>  i:i  1. 1 vsr.s. 


:!I7 


•J  ..?vXl 


.1: 

_ asm 

111 


If  ' 


n 


V-t  ---i 


34a 


/ )  riinih  II  I  /  /; 


r$   .... 

^     ■ 

?   ■  •    ■ 

..         ..        .    .^ 

>;   ; ;  1 : 

,5      ■  •  ■ 

:$  .... 
s  ■  ■  ■  ■ 

r* 

1  CD 

S     ■ 

< 

^. . .   . . 

rs-;;;;- 

.-5     -  ■  •  - 
^     .... 

1  rt      -   ■    •    ■ 

n     ■  -  • 

0 

f, 

S  •••• 

fj 

1  «?      .... 

Tl 

fl 

**•        .... 
N 

r-i     ■ 

< 

...  ^ 
: . .    < 

> 

>     •: 

* 

> 

>-.   : : ; : 

I,- 

— —  ■•  t ' ' 

-—-i-f-* — 
— —    .11 

-     '    '    '  T- 

■     :'-ti: 

M             ■    •     ■ 

-         .... 

.    ^    -    -^.  .     .  -     -. 

H    ■  •  ■  ■ 

!  2  : : : ; 

— ■-'— 

=£=: 

;;;'«; 

.'<■ 

■  ;       .  ■ .  .^ii  . 

■  ■;•!■ 

j  fi , 

...   _.- 

—    -^ 

>     ,  ■ ': 

c      .... 

\^ 

. . . ,-. 

«    ■  ■  ■  • 

^>  ■ 

X        ... 

K 

r;^-' 

(0     .... 

- 

■              <^ 

__^ 

1     t-;    5: 

? 

> 

at              Q, 

»5                  C*t 

s      s 

-  a 


w-^ 


/{/ '  /.T/'/  >'  7  .V  />     IN/'    l:l  I    !'">/>'■ 


?A9 


If  tliif^  lie  cimpMnil  \Mlli  lli>'  nilliiT  liiiv  cn-c-  in  uliirli  it  ua-  |m,— il.lc 
t.i  iiiakr  "l.-i  ■•>  iili'iii-  "I'  lli«'  I'lil-"'  :i-  ""I'ly  •'"  ''"■  I"  ''''"'  "'  iii'"l''i'i"".  •' 
(ilrikiiiir  .•.liihiilriirf  of  \\\v  i)iiU.-ir;ii  iiiL'  \»\\<U'  iln-  1m -iimiiii:  "I'  ll"' 
|iririi:irv  :ilt;i.k  uiili  lliiit  |.rir.-.lii|._'  tli.  n  lii).-.'  will  l.r  ch-.ii-r.l. 
TIhTc  will  ill-i.  \»'  tollliil  :i  rc-.|iil.l:ili.c  ImInm.ii  llir  lrl:i|i-i'  :ili<l  til' 
pritiiarv  attack,  inaiiilr-tnl  in  tlir  tiiiiiMnitiin-cuis  c-,'  ami  ni  inaii/ 
other    liatiiir-i    hi-idc-. 

All    iii-tnutivc    iii~taiir.'   d'   a    iiiild    rrla|i-c    willi    tln'    i!iara<t.Ti-ti(; 
f.atiiri-  iit'|)iil-.'  ami  lriii|Miatiir.'  jii-t  ili-cii-M.l    i-  atV.>nl<il  hy  l'"i^'.  ;!•). 

Witli  ri'traiil  t.i  till'  -tatc  of  tin    tiiiii»nilun'  ilmiiiu'  the  f.lirilc  |wri<Hl 


|..n   ,,f  (h.    ■\ 


rill.  ^T.-Ti'iiiiKTiituri' cliart  fn.in  ii  iiH.cl.riit.ly  scviTC.  rnitructiMl  nisc  r.f  typhoid  fi'V.r  in  a 
Fcrvniit-Kirl  iiimt.-.  ii  yiMirs  nl,l.  A  nlupsu  si'l  iii  ..ii  liic  furty-tlrsl  .lay  nf  llu-  aiaeaso,  witii ;  up- 
like  nsctnt  <if  till-  tiniinTiUiirr. 

of  the  rocni<lf>>  ^Micc  and  the  relapse,  l«ith  the  iliiration  of  its  elevation 
anil  the  cliaraeter  of  the  curve  are  extremely  varialile,  just  as  in  the 
primarv  attack.  l>e!ap-e-  may  occur  with  fever-period-  of  from  eiirhteeli 
to  tweiitv  days,  and  even  loiiircr.  They  not  rarely  exhihit  ( i'itr.  •"'•>) 
almost  exaetlv  the  same  coiir-e  as  moderately  -evere  or  mild,  typical 
attacks  of  tvphoid  fever.-  Kclajises  of  much  shorter  duration  (Fii;.  .">7) 
ni,  V  lik<\vi-e  exhihit  di-tinctly  all  the  usual  stajres. 

In  addition  to  these  varieties,  relajises  purMiini:  a  mild  ooiirsp.  of 
greater  or   lesser   duration,    often   ijuite    coiisidenihly    protracted,    with 

1..      T-.       .,   ..    ._!  ,,.  ; /' „..-..!.■;.,    11    r,    lin 


;].-,o 


TYriioiii  i-i:\i:i: 


'i'-i'l' 


invLiul.ir.  .It  liiiH-  iiilii'(l\  iiiirliaiai-ici-i-ili-,  iniijicratiiri'-i'iirxo.  .■ht  in 
L.'<n(i-al    iiilii.  I-    rivi|ii(ni.      'I'lic    >1iimI    and    llir    -lioMc-i    iTla|i,-f,-    liiiallv 

i''|iri"l \Hlli    i(  li  i(  n.r  Id  .haraclii-  ami  cmih^c.  all   the   tialun-  tliat 

"!■  Iia\i  liic'.nic  liiiiiiliar  willi  a-  liclniiijiiiM-  \,^  \\\^■  -viniildnialciliiiiA- 
iif  iiiiM.  niiM.-l,  anil  aliiiitivi'  ca-r-  ,^\'  l\|i|ii,ic|  I'cvci-.  In  inaiiv  the 
la-li;jiuni  i~  Ihii  i.f  i.i  I.  r  (Inralinn.  an<i  in  -unir  ca-c^  il  i  t  nlii'i  U  wanl- 
in^j-.  in  liial  llir  n  in|i(rilnrc  fcniaiii-  Iml  lrin|Mii'ai'il\ ,  (  I'lin  l^r  a  \\\\ 
hiini-  cnlv ,  al  ilic  In'jlic-l  lr\il  ivarlicj.  and  ilun  dirlinc-.  .\ni  ](-> 
vaii'd  i-  llic  (liaraiti  I-  uf  llu'  a-ciiil  ami  llir  di  cliiic  of  th,'  cniA.'  in  llir 
mild  and  -hurl    r(la|i--r-. 

ll  i-  |iarlirnlail\  inlc  iv-iiiii.'-  that  llir  cliaractir  and  tlir  |ii(ailiarilic.- 
iit  'lie  riir\r  in  ilii'  |  n  i  In,  i  r\-  a  I  lack  aiT  tVi  i|iiinl  l\  rr|]|'(idiiii(|  Imlh  in 
llic  K  iaiid( -CI  iii-i  and  in  lli  rcla|)-<.  al  lime-  c\cn  in  a  niiuT  cicarlv 
ddiiicd  inaniicr.  Tlii-  a|i|ilic-  c-|ic(aally  Id  ilic  inarkc<il\  rcniiltcnt  cn- 
iiitcrniiin  111  l\|ic  dl'ciMAc.  ..',■  which   |-"ic-.  .".s  c(,ii-lilnl(-   an    illii-lralidii. 

ll.  tiirlhcr,  liic  i-haracici'  d|'  the  individual  |iail-  cf  liir  curve  in 
rcla|i-i'-  lie  inv(-ii_  III  ll.  a  -linilaiilv  will  lie  rdiind  In  ihc  cdndiiidus 
ii^ilallv  pi'i-iiil  in  ]iriiiiarv  allack-.  The  liirin  nf  I  he  a-ccndiiii:  ciirv  <•  i- 
iiid-l  In  i|Uenllv  -ic|)-like  ill  i  he  cn-ioinarv  manner.  evncralK  -uniew  hat 
-lidrliiied  ill  I  diiijiaii-dii  \viih  the  -aiiie  -la-c  d|'  ihe  |jriin,arv  allack.  lo.-i 
(■iininidiilv   df  (ipial  diii'alidn. 

In  dlhei'  ca-e-  ihe  icin|ici'al lire  rcaclic-  il-  aiane  at  a  -iiiiile  lidiind  nr 
with  liiil  diie  i.r  tvvd  liiiet  inli  rnii--idii-  (  I'i^-.-.  :!>,  :V.K  and    |ii).       I'lidcr 

th(-e  ciivnni-lance-  ll n-e|  nt'  t!ie  ivla|i-e  vvllli  a  chill,  which  i~  dllicr- 

v\i-i  vii'v  rare,  i-  lVei|iienlly  dli-irved.  ()lher  rai'c  caM'~  cxhiliit  the 
|iccnliar  realnie  i^\  niii'  nr  -evcral  marked  llnctiiatidn-  in  the  teni|iera- 
Iille,  with  cdii-ideralile  eveiiiii:;-  elevatidii,  i)fli)rc  tiic  .-t;li:c  dt'  dcliliitc 
aM-eiit    lie;jin-   (  |-"i;j:-.    .■;.")   and     HM. 

In  addiiici:  td  the  t'drcLidiiii.'-  varieties  .if  curve-,  there  dccnr,  (-[le- 
ciallv  at  ihi'  he'_dnniiiL:  ut'  rela|i-e-  |inr-iiiii'/  an  irrci^nlar  cdur-c,  a 
iminlier  dfullier-  v\hicli  are  di-limllv  related  Id  ihc  like  I'drin-  T  i'evcr- 
a.-ccnt    in    the    |iriniarv   .iitack.       Il    mi'd    unlv  lie    meiilidiied    further    in 

'lli-  mectidii  that  ll ii-i  I  inav  he  attended  with  aliiidrnialiv  marked 

remi--idii<   in  th  ■  tein)icratiire-ciirvc.  w  liieh    inav    jn-lifV  the   e\|iectatidii 

"!'  the  -an r  dl'  ,i  whdjlv  inlerinillent  character  nf  all    the   -iiccecdiii;; 

]idrtidj)-. 

The  cdiir-e  df  ihe  lem|)eratiire  at  the  lieiLilit  n\'  the  i'evcr  i-  in  rciap-cs, 
a-  ha-  i>ei  n  eni|ilia-i/eil,  in  niaiiv  re-]>i'ct-  like  thai  in  ihe  priinarv 
attack.  When  the  I'l-li-inni  ha-  ]ier-i-lcd  fur  a  cun-idcralilc  litne,  the 
tciii])cratiire-c|i art-  will  i  ..liKit,  jii-l  a-  in  the  |iriii)arv  attack,  the  cliar- 
acter>  lit'  rcuiittciil  (•iiiitimi('<I  (ever  ur  uf  ilic  iiidi-c  marked  rcmittcut  or 


■f:±\ 


n i:<  11 1  i>i:s(  i:.\( ■i:s  .wd  i: i.i. . i / •si:s. 


•^:,i 


tlic  almost  intcriiiiil<iit  forms  df  tlvcr  ( I'itrs.  .iS  and  'J!*)-  Tlic  ju'riod 
lit"  iiiiMt,  cntii-fly  liki'  that  of  tlic  priinarv  attack,  i~  u-nally  iliarac- 
tori/vil  liy  step-like  or  eliaraeti'ri^tie  steep  eiirves  (Figs.  ;Uj  and  oT). 


I 


!»'  lit; 


WiX 


■^*.  ^--  't*. 


sr)2 


TVi'imni  ri:vi:i:. 


'I'l  rfiiiiiiiliiiii  III'  till'  niiji-.'  liV  i'iilic:il  (Ircliiic  i<  rchitivcly  r;ir('.  A 
).'|-;iiln;il,  riiiii'cK  imcliai-arlci  1  tic  ilivliiK,  \\it|i  ;m  iiTi'^iilar.  (il'tcM  ]irii- 
traclnl  nMii-.t',  cir  -uli-iilciHT  will;  maikiil  iiilcriiii--iiiii-.  i-  innic  fic- 
nuiiil  ;  llii~  (iccur-  :iir:iiii  <'~|icci:ilU  in  ca-i-  in  wliicli  aUn  tlic  |ir<c((lint: 
>lML^f  cxliiliilccl  a  -imilar  chamrli  r  nl'  ciiivc  [V'vs.  -ilM- 

'I'lir  |inl-c'  i-  i;iiicTall\  iii'H'c  tVr(|iii'nl  in  tlir  nla|i~('  llian  in  llic 
iiiiinai'N  allaik.  In  women  ami  ilnhji'cn,  ami  in  men  ilcliilitalid  liy 
the   antcicilrnt    altaik,  ilir    innnl>rr  ol'  jiiil-i-liral-    i-   even    likely  to   lie 

niin-n  illv  lii^:!!.     A  |inl-e  ot'  TJn  in  the  e\  inini;  i-  tlnii  mit  a  v.w ■enr- 

n  iiee.  ami.  il'  llie  eunilitinu  <!■"-  nut   iiei--i-l   |o|-  |(Mi  \,iw^  a  lime,  it  i-  Jiut 


i|   tlr     .li-  IIM'. 


24  2h  26  27  28  20  30  31  32  33  3't  35  36  37  38  3«  '»0  V.    42  'iS   Vi  '^6  '!9 


Fir.,  ■:,'. 


even  (if  e-|ieeia!lv  -eriun-  im|i"rt.  In  aiMili"n  to  tlie  inefeascd  lVe(|nency, 
llic  |inl-e  (InnMiX  lln'  rela|i-e  i-  al-i>  eiiai'.ieleii/ed  liy  L-rcat  \  arialiility. 
|-;ven  Mil  A\'j:\\X  ]>liv-ii'.il  cir  mental  exertion  it  may  lie  lieyoiid  enmim- 
talioii.  ami  in  adiill^  inav  ivaeli  1  .".(l  or  1  |ti.  Tlii-  iiiM.al.ilily  of  the 
]iuKe  make-  itself  a|ijil-eeialile.  a<  ha~  Keen  -eell,  a-  earl^  a-  the  |ieriotl 
of   ilielilialioii  of  the  l-ela|we.        All    ill-triietive    illll-l  rat  ioji    of   the    ehaf- 

aetei-  of"  the  [inl-e  ill  this  |ieiio(l  ami  iliiriiit:  the  I'elnile  period  i-  atlinded 
liy  l-'i-.  .■'..■|. 

])i,-i-,.!i-ni  of  the  piilse  i-  d'tiiiitelv  Tiot  so  fre(iiieiitly  observed  diiriiiir 
the  relap-e  a-  diiiiiii:  the  jirimary  .attaek.  It  i|uil«'  lieiierilly  fiil-  to 
appeal'  even  ii;   tlio-e  ease-    in  whieh  it  was   previously   eNeeediiiirly  well 


iJ! 


v'-''^:^--._v:'':\"  "j.'vj:;. 


,u.:  ii:.-  ^..^^'..iiii'i:/;;::, 


";>_\,V.    .;,  ■.;^.  r-"--!"?-. 


/I'Av 7; ? -i)i:s( ■i:.\( ■i:s  . i .\7)  hei.a rsi:s. 


■Ary.i 


marked.  Wlicii  the  iiiaiiilrstatinri  (icciirs  at  all,  it  takes  jilaee  in  tlie 
course  III'  tlie  >evere,  protraele*!  relapse  having  an  e»|ietially  |)ni|(iii^e<| 
fa.-tii^iiitn.  In  ~neli  eases  svMi|)toins  nt'  eanliae  weakne.-s  al^i  hei'dnie 
apparent,  wliieli  (iilier\vi.~e  are  not  eonnnnn.  1  ireL^iilariiy  nj"  the  pulse 
also  is  eoniparalively  rare.  It  likewi-e  oeeiirs  alnio-t  exelnsively  in  tlie 
most  severe  relajises.  Slow  int^  ot'  the  |iulse,  which  is  so  conitnon  in 
roliust  viamjf  men  diirinir  the  jirimarv  attack,  I  have  never  observed  in 
relapses,  even  in  such  iiidi\iduals. 

The  hehavior  ot"  the  ro-cohe  in  the  relapse  is  most  important,  e-pe- 
liallv  iVoni  a  dia!j;no.~tic  standpoint.  I'heir  appearance  may  lie  actii- 
allv  deci-ive  in  diai:no>i~,  e~peeiall\  when  doiiltt  e.\i>ts  whether  the 
reasceiit   ot'  the   lever   may    not   he  attrihntetl   to   M'Vere  complications, 


lliiv  uf  th.    ci;-,;isi'. 


Ifl 

l.t 

20 

21 

2"^ 

2n 

2h 

25 

26 

27 

28 

29 

30 

;ii 

32 

nn 

S'. 

3  J 

3fi    37 

38  3  a 

W) 

m  i* 

'J  w  't 

4 

Temp. 

j 

: 

:" 

-  +- 

— f— 

^- 

"^ 

-1-  4- 

i- 

-i. 

~ 

-; 

• 

~ 

39 

■ 

'  ^ 

•- 

^  'V 

'  r 

■^ 

^1 

f^} 

„ 

* 

1 

rin 

\ 

A 

'■ 

■ 

- 

1 

T 

7l 

,     ,  ^_ 

f^ 

/ 

h 

I .  * 

~ 

i 

Z- 

■^ 

37 

'-] 

lA 

^ 

A 

th.^i^ 

/ 

-+- 

— 

H 

£_i 

1 

3(1 

-] 

I 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

/ 

•f 

/ 

1. 

■  ■* 

V  ^ 

i-  - 

ft: 



" 

fr       ,- 

1  -^ 

- 

-f---t--4- 

-+-  ■-- 

-I-  - 

- 

35 

'; 

t 

J 

-  + 

I 
- 1- 

t 

-1 

-i-- 

^t- 

-t- 
4^- 

t 

-4-- 

f 

i' 

t 

-i- 

^- 

t 

4::::: 

— 

-+- 
-1- 

.!     ^ 

X    .- 

1    1    1    1    1 

^  .^-  - 

^ 

Fii;.  40. 

as,  for  instance,  septic  states  or  miliary  tulierculosis.  In  <renenil, 
their  developmcLit  during  a  relapse  i~  ipiite  usual — in  my  experience 
scarcely  |e-;s  common  than  durintr  the  |)rimarv  attack.  In  l2!i(i  ca.'^es  of 
relapse  e.\amine<i  with  reirard  to  this  jwiint,  I  ti)und  i-oseolie  douhtful  or 
absent  in  •J.">.7  per  cent.  It  is  true  that,  as  with  reirinl  to  so  many  condi- 
tions in  ca-cs  ot"  typhoid  fever,  the  pc<'uliarities  of  individual  epMcmies 
must  he  taken  into  <'onsider;ition  in  this  conne<'tion  also.  I  have 
myselt'  ohservisl  |)eriods  in  which  the  roseohe  were  even  more  frcipieiit 
than  has  ju>t  Ihhmi  mentioned,  and,  in  addition,  we/e  al.-o  remarkahlv 
profuse;  and  others  in  which  they  were  disiinctlv  less  cummon  and  less 
ai)undant.  Their  lumiher  and  <>xtent  in  the  indiviilual  case  are  ireiier- 
ally  xmiewliat  smaller  than  in  the  primary  attack  ;  hut,  on  the  other  hand, 

25 


wm 


14 


?--J 

K; 

- 

i 

3M 


TYrii'iin  FEVi'.n. 


tlic  coiHlitiiiii-  (ili-irvcil  <liiiiii_''  llii-  I"  ridcl  arc  rcpfatinl  witli  rciiiitrkaitli' 
(h'luiciicv  ill  tlir  ivl,i|,-r.  Only  ill  -really  ndiiecd.  (-pr.-ially  -ciiii.' iiidi- 
vidiial-.  iiiav  the  m-cohr  \<v  iviiiavkaMy  pair,  -inall,  and  1.—  (•irvalc<l. 
Ill  -II. 'h  <'as(-  iiidi\idual  I'M-cola'.  it  i-  Inic.  luiy  r\(vi.ti..iially  l.rcoin.. 
liciiii.i-rliaLlic,  "1-  actual  |m  livliia'  may  a|«|icai'.  c-pcrially  in  tlic  iiypoiia-- 
iriiiiii  and  tlic  a.iiacciit  i">riioii-  "f  tlir  lliii^li-.  In  accordance  uilli  llic 
more  i-a|ii<l  coiir-e  ,,1'  ivcnide-ceiicc-  and  ivlap-c-  in  -eiicral,  the  ru-c(.l;r 
al-o  !ii>|iear  Huncwlial  cirlier  tliaii  in  the  priniai-y  attack.  Mild  and 
severe  ca-c-  exhiliit  little  ditVcrence  III    thi-    rc-ai-d.       It    i-    p"-.-il,ie   that 

ill    the     -e\civ    pi-ntracted    ca-c-    tl riiptiMii    aplpcaf-    -oiiicwhal     lalef. 

I  have  III. -I  riv.|U.Mit!\  ul,~er\(d  the  n.-euhc  tu  appear  diiriii-  the 
rclap-e  I.etwci  M  the  thvl  and  the  Hfih  day  ;  -oinewhat  le--  c(miiihaily 
,,n  the  M'cciid  or  tile  ~i\th  day  ;  iiiiich  le-  ennimmily  at  a  later  period. 
In  oiiK  -1  in-tance-  h  i\e  I  oh-erv.'d  ro-eoke  to  :ippear  on  the  tenth  an<l 
the  loiirteeiith  day^  rc-pecti\cly. 

I  have  aiiah/ed  ahoiii  :;iii)  .-im-  .i'  rchi|iscs  uitli  i._-ir.l  to  thi.-  point. 
The  fn>t  appearance  ,.f  ihe  re-eohe  tVoiu  the  tir.-l  to  the  ihir.l  day  »a>  iinted 
in  X.7  jicr  cent.;  fmiii  llic  tonrth  to  ihe  >i.\tli  day  in  ti"!.-"!  per  cent.  ;  en 
the  seventh  dav  in   14..")  per  cent.  :   after  the  seventh  .lav  in  .">  per  I'fiit. 

The  .liirati.Mi  .>t'tli..  individual  r..-.  — i".t  u.i-.  in  L'eiicr,il.  not  -h..rtcr 
than  iti  the  primary  atl  i.k.  N.w  .riiiition-  and  rc.-rii.le-iviicc-.  ol'  the 
cxantiiem  al-.i  occiirrc.l  in  -ever.'  and  proira.-t.d  r.lap-.-  Jn-t  a-  . ■.mi- 
ni.iiiiv  a>    in    ill.'    liriinii'^   atla.-k. 

Knlarei'iiicnt  .d'  th.'  -pl.-.n.  a-  ha-  lic'ii  m.iiti.Mi.'d.  .it't.ii  doe-  not 
snh-i.l.'  i'.itiiiil.'t.'ly  att.r  th.'  i.riniarx  -iih-i.i.n.'.'  ..f  th.'  I.'iii|"'ratiir.'  in 
ca-.'^  in  whi.'h  r.'la|.-e-  ....'iir.  It  may  .vi'ii  r.niam  palpal. h'  diiriiiL' 
the  entir.'  inl.rval.  an. I.  in  .'..nn.'cti.in  with  the  p.'ciiliai-  .'hai^K'tcr  ..f  the 
piil-c  an.l  I.  iiii>.'ratmv  pr.vi..ii-ly  .Ic-irili.'.l,  may  dctinit.'ly  -ii^'^'ost  tlic 
imiM'tidinir  niai.-e.  r..'f.ir.'  l.aMiiL'  ...n.-lii-i'm-  iil"'ii  th.'  -tatc  .d"  the 
sj.lccn.  li..\v.'ver.  ..tie  niii-t    have  a-nr.'.i   hiin-.lf  that    pr.'vi..ii-  .'idai'-c- 

,ii,.,,t    of  tl ivaii.  .1  1.'    tl.  ..ther  .'.iii-e-.  ha. I    n..t    exi-tcd    pri.ir   I.,    th.' 

atta.-k    ..f  typhoid    t'.'\.r. 

M.,r..  fre.pi.'iit  than  th.'  p.  r-i-tcn.'.'  »\'  -pl.iiic  .nlaru'cmi'iit  i-  it-  L'tal 
di-app<'araii.'.'  in  th.'  int.'rval  1.  tw.'.ii  th.'  i.i'iin.iry  atta.'k  and  the 
rclap-e.  Th.'  iii.'iva-.'  in  -i/e  tli.  n  aLT.'iin  '".'onie-  d.inon-trald.'  diirini: 
the  first  da\-  ..t'lh.'  r.lap-.'.  in  irciicral  s..ine«lial  .arli.r  than  diifili^'  the 

fir-t  atta.'k in  niv  opiiii..n.  Ii.lw.'.'n  the  third  an.l    tlic  -ixtli  day.      'Ihe 

cases  ar.'  e-pciially  n..t.'\v..rtliy.  an.l  ..f  impo.-tanc.'  from  the  .liaL'iio-l  i.' 
.standpuint,  in  which  .'iilafircmeilt  ..f  the -ph'en  had  l>"cn  entiivl\  uniting' 
<liirinL'  ttic  ].rimary  f.  l.rilc  |.eri..d,  ami  l.ccanic  iiiic<iiiivo«illy  dciiK.n- 
.strablc  during   the   relapse. 


'^■*\ 


1:1.1  i:ri>i:s<  ■i:s<  />  .1  .\  /<  i:i:i..\v^i:s. 


1  iiirnr  witli  /iriii-^scii,'  \v!iu  pn-ci:!-  v;ilu:il-l"  -!:iti-ti<--  in  -ii|>]".rt 
III"  hi-  -I;'lcllli'lll,  lliat  tlir  (■IlliirLrrlMi'lIt  ut'  tlir  -|ilf<ll  ilurilii:  tlic  ITclllilc— 
cciirr  mill  llic  itI:i|i-c  i-  iiirclv  ltimht.  IiiH  nviicnillv  i-  Ic— ,  lliMii  ilnriii^ 
till'  priiaiirv  aiiaik.  .Nrvcrilirlr— ,  1  liavr  uli-ci-v nl  ikiI  a  liw  ca-i- 
iii  wliirli  ciilarL^ciiiciil  <<\'  llic  -plrni.  appiviialili-  iliiiiiiLT  llir  priinaiy 
allark  iiiilv  nil  |Mri-ii--iuii.  Iinaiiir  a|i|ir(rialilc   mi    ]ial|ialiiiii   iliiriiiir   tln' 

rclaii-c.      Ill    tlii ■riinii,  il     i-    triir,  \\\f   ^nval    cinacialiuii    ami   tlir 

ri'la\atiiiii  of  till  iilMluiiiiiial  wall-.  |priil)alily  al-n  tin-  Ic—  iiiarkcd  iiiclcni- 
i-iii  (iiiriiiLT  till'  icla|i-r,  may  l"'  nt"  -iiiin'  iiii|i"nam-r. 

Tlir  -vm|itiim-  rrt'rraMi'  In  lln'  iiili-liiial  ,anal  liitVci-  I. ill  lillli'  iVntii 
tli.i-i>  ill  the  |)riiiiary  altarU,  ami  at  iiin-I  mily  in  ilrLrivr.  'I'lii'  iiirlrnri-iii 
rai-civ  allaiii-  markcil  iiitcii-ily.  Tin-  Imwil-  arr  varialilr,  a-  in  tln' 
|iiiiiiar\'  altai-k.  At  tiim-  tlirrr  i-  ilianlira,  'Ailli  -mnl-  nf  i-lia!-:iclfri-lii- 
ciiliir  ami  i-mi-i-l'iirr  ;  ami  at  ullin-  linn-,  mi  tln'  im.l  ,ary,  cmi-liipalimi  ; 
,ir  one  Mia\-  allmialc  uilli  tin'  hiIht.  Analmiiir  cxaiiiiiiatimi — till- 
,-lali'imiil  i-  lia-ni  ujvmi  llir  lomliliiiii-  r.iiiiii!  in  -'11  ra-c-  (•xainilici 
|i,.|v,,,iall\- — (li-cli.-i-    witliniil     r\rr|ilimi.    ill    ailililimi     U<    mmv  nr    li-,- 

rcrciit     ciraliicr-,   m'    rlcaii,    al !     liralnl     iilni-.    ri-iillinu'    I'l I     llic 

pi-iinarv  attack.  I'lv-li  innliiUafy  -wcUinu-  nf  Iimi'-  |(atr!ic-  ami  tlic 
-iilitarv  Jiillii-li-.  in  pari  in  prnci--  n|' -Inii^liiiiir  m-  liririniiinLr  nlrcralinii. 
N'nt  I'arclv.  iniilrr  >m'li  circnmstancc^,  in  adililimi  in  cicalri/cil  |Kirt;mi- 
nl'  a  l\\crV  |i;iiili.  f'n-li  iiifiltfalimi  nf  pn\  inii-ly  iMinpt  portimis  nt' 
tlir  -ainc  jialrli  mav  he  nli-crvni.  In  aiMiilnii.  tlicrc  al-n  («'ciii's  tVi-li 
-wclliiiLT  nt'  the  iiir-cntcrir  trlaml-. 

Xo  ilfliiiiii'  I'fl.ilinn  cxi-N,  iil)\imi-ly.  luiwirn  tlir  rMcnt  ami  tlu' 
inlrii-itv  nt'  tlic  fccciit  inliltialinn  In  ilm-r  nf  the  prcv  inii-  uiic  I  luivc 
nliMI'Viil  tiir  ni'W  inlillralimi  In  lie  i|Uitr  cMcll-ivf  ill  tlic  prcsi'licc  nf 
i-nJat'Ml  liialiiiT-  ;  ami,  (■(iiivcrscly,  liavr  nli-i  rvnl  only  i-nlatiil  t'rc^li 
-unllcn  iiatrlics  or  fnllirlcs  after  vrry  inarkcil  primary  iiitc-tinal  K-imis. 
On  tlir  wlinlc,  linwi'ViT,  till'  iiitc-tiiial  Ir-imi- nf  ilir  rrlajiM'  arc  ili>tiii('tly 
lis-  iiinncrmi-,  ilccji.  ami  cxtcii-ivc  than  ilm-c  n['  the  jiriinary  attack. 
I'niloiilileil  relap-c-.  a--ncialcil  with  mily  ncent  catarrhal  liimel'aetimi  nf 
the  nuicmis  nieniliraiic  anil  nn  alteratimi  in  the  I'nilielcs,  <iieli  a«  have  liecu 
clc-erilicil  c-pci'ially  I'y  {'"reticli  in\  c-iitratnr- (Cmnil).  have  af^  yet,  imt 
ncciii'i'eil  in  my  experience;  lint  in  the  liirlit  t<\'  eurrcnl  emu'eptimi^  the 
pn--iliility  nt"  ihcir  neciirreiice  !■;  certainly  iinl  In  he  denied.  In  the 
niainriiy  nf  case-  the  frc-li  medullary  -wclliiijjr  a!-n  ne('iir-  in  tlin>e  pnr- 
tinii-  nt'  the  intcsiine  prei'eralilv  involved  in  the  |>riniarv  attack,  in  the 
iiiid-t    i\[\    ..r.    iiinre    fVeijiieiitly,    Miinewhat    remote   from,    the    )>rin;ary 

'  Wiii-zhiirri.   Jnlii-(Jr:iiiil  -Srhn/t.   1882.  iinil    l>nitsi-l,.    An-li.    f.  Idiit.    Mo/..   \W. 
\  \  \  i  V . 


■*  ''J*  t^ 


-^.■r  ^.     '-■»: 


^j.rli''^' I 


:)ti 


rvriinii)  I  i:vi:i;. 


Ic-iciii-.  It  line-,  iidWevcT,  incur  iml  ;il  :ill  r;iii  iy  tii;it  ]Miriiiin-  <if'ilil(>- 
tiiic  atViM-iiil  |ircvi'iii-K'  in  -li^rlit  <li;.'n'r,  iC  at  all.  Iicinuif  ilic  -cat  ul' 
iiiarUiil  alt(ratinii>  dnrinix  ilif  nlap-c  Tliii--,  l^r  in-iamc,  1  have 
nl).(rv((l  in  a  i"i-i'  ut' ••  culdn-l  vplinid  "  i(<rnl  iilcir-  and  ~\\<llirij;  in  llic 
rtMiiiii  ,,t'  ihc  iiiiiccral  va!\c  and  llic  adjacTnl  imrlinn-  ■<['  \\\v  ilcinn, 
uliirli  |ii'(vi(in-l\    wcir  li  It  alnio-i  inlait  ;    uliilr   in  oiIkt  in-lant'c-.  I'lm- 

vtr-c!_\ ,   1    liaxi'   l'( d   nlcrfati if  the    Inllicli-   in   iIjc   larp'    intt-linc 

when  lln'  i>riinarv  allicliuii  a|i|pai(iitly  inxoKrd  alnin-I  mdy  tlic  l.iwir 
|«irti"n--  lit'  till'   -mall   iiitr-tinr. 

'I'lir  -liu'litir  ili'V('lii|init  lit  nl'  itic  anaimnic  altcratiniis  in  jxi'in'ral 
(■\|ilaih~  al-i)  tlic  cii-i-imi-tanrc  lliat  lirniiii-rliai.'t'  ami  pcitiiratixc  |n fitii- 
nili-  air  laf  It— riiiiiniiin  ilnriiiL;  rila|i-<- and  niTudt-riiiii  -  tlian  diiriiifj 
tl'r   |iiimarv   attarls.      W'liilr.    t'nr   iii>tanii-,     in     IlamlmrL''   wr   nli-crvod 

amiiiiij:  a    tnlal    nl'    :liiMi   ca-r-   nl'  ty|ilii'id    t'i\rr,    1  "i-'l    ra-i l.jti    jht 

cent. — willi    iiiti-tinal    lirinnrrliaLir,  tlii^  iMTi:rrcd    in   Imii     I  aim  nit:    "i-'l 

rrl.,|l-i I'.Tli     |Mr    rillt. 

W  itli  rctiiTiici'  til  till'  rc>]iil'atiiry  a|i|iaraiii-.  lill!"  i~  i"  lie  -aid.  In 
MMTr  and  iirntfactcd  nla|i-('-  lirmirlnl  i-  ^riirralK  aiiain  dcvrlup-. 
'I'lii-.  it  i-  tnif,  mav  lir  nl  alari'iiii'j  -r\(  ril\  and  cxlriit  in  nld  and 
diliilitatcd  iiidividiial-.  and  may  rvrii  Irad  tu  jiy |iii-tati('  (■iii);x<'>I'"ii- 
Till'  dcxrluiimcnt  ul'  pncnniniiia  and  plmii-y  i-  riniipai'ailvcly  rai'o. 
Tlii.-    i-   a|>iili<'alilr  r-picially    ti   Irur   tiliriiiuii-    pmuimiiiia. 

U  illi  ri'irafd  In  tlir  ill  rvmi-  -y-tiiii  aUn  tlicri'  i-  littlr  nt"  -pccial 
iniiNirlam'f  tn  ln'  miiitiiMicd.  In  imidiinilc,  -Imrt.  ami  mild  rcla|)M'S 
tlic  cases  arc  in  lid-  rc-pcd  nficii  icmaiUalily  umninplicatcd.  In 
severe  |)riitfaeted  relap-c-.  i-]ieiially  tlinsc  tliat,  a-  appear-  tn  inc.  ueetir 
alter  a  mild  primary  attack,  the  jiatieni-  at  time-  exliiliit  \  inlcnt  .delir- 
ium, nr  tliev  iiiav  mhui  tall  iiitn  a  -late  n*'  -npnr,  and  even  nt'  alarmiiifr 
enma.  I'neal  le-inii-  nt'  tile  central  nerviiiis  -ystcin  nr  clianjr<'-  in  the 
iicriplieral  nerve-,  with  enrrc-pnndin<j:  se(|Uel-,  arc  di-tinclly  less  enin- 
mnnlv   ,■|^-(lciatcd    with    rela|)ses. 

Course  and  Terminations  of  the  Relapse. — While  we 
have  as  vet  liccn  imalilc  tn  di-i  ■.niisli  any  material  ditl'crciice  hclwccn 
a  recriidc-ccnce  and  a  rela|i'e  with  rcL'':ird  tn  theeiiiir-e  nt'ihc  t'cvcr  and 
the  chaniT'-^  i'l  'he  vi-cera,  sneh  a  diU'ereiiec  nndniihteilly  e\i-ts  with 
reference  tn  the  irencrid  cniiiM'  and  tcrniinalinn.  The  true  rccrii- 
deseeiice  exhiliits  iiinrc  t'rc(|iieiitly  than  the  relapse  a  sevi'fc  cliiiical 
jiietiire,  e\cn  when  the  cniirse  nf  the  fever  is  of  the  same  diiratinii  and 
character  in  each.  One  aliim-l  tret-  the  imprcs-inn  that  the  patient  in 
the    relapse,  in  cnntradistinetinn    tn  the  patient    sntVerinfr  finm    a  reerii- 


m 


j:i:ri;r I >i:s(i:\( ■/:.■<  .\\i>  /.•/■/..i/'v/x  3o7 

<l('scciici',  lias  already  liad  an  .i|>|M(rliiriiiy  to  i-(cc(V(r  iliiiiiij,'  tlic  alll.ril.! 
inlcnal  ami  to  t'ortity  liim.-cll'  airaiii-t  the  new  attack. 

Also,  voii  /,ii'iii--fii  tin|ilia.>'i/.c.-  I  he  xvcri-  coiitm'  ot'  i-tirinlcs.  fiicf.-.  He 
rccordtMl  severe  syiiiptdiiis  in  ,')()  |„.|-  ,.,.||t.  (,f  recnideseeiiees.  and  oh.scrveil 
;ls  iiiaiiy  as  l.i  per  cent,  teriiiinate  tiilally.  .M\-  nwn  slatislics  are  soine- 
wliat  more  luvoralili-.  (  »f  1  in  rernideM-eiiees.  the  emir.-e  \\a.>  severe  and 
alaraiiiii:  in   10.  while  1  I   per  c,  nl.    teriniijaled  latallv. 

Altlioii^rl,  ill,,  aetiial  relap-e-  wilii  a  liitrlily  til. rile  and  protnieled 
e(.iir~e  may  aUi)  ,\liiliit  a  -evere  clinical  pieiiire,  tlii-  i-  far  les-,  c.rn- 
liioii,  and  the  mortality  is,  on  the  whole,  much  lower,  than  in  the  recru- 
descence-. Kvcn  in  the  sevefe.-t  I'pidemic-  tin-  niortalitv  prohaMv 
scarcely  ever  exceed-  .".  per  cent.  ;  •_'.•'.  j.cr  cent.,  or  at  most  i  [mv  nt., 
is  prohalily  the  ii-nal  mortalitv. 

In  the  epidemic  at  HandiiirL'  the  mortality  during'  relapses  was  relatively 
high,  namely,  4.'.t  per  cent.  i.\mom.'  all  fatal  ca.ses  of  typhoid  |,ver,  the 
proportion   of   those  oceiirrim:  dnrinir   relapses   was   (•.?    |ht    cent,  i       ( >nr 

•statistics  at    Leipsic  exhiliit   a    rtality  of  not  (piite  L'  jwr  cent.  ;  those  of 

Ziems.seu,  2.H  per  cent.  Steinthal,'  it  is  true,  reeord.s  f<.,s  jK-r  cent.  As  this 
estimate,  however,  is  hased  upon  only  A't  relap.s«.s,  accidental  iiilluenees  are 
not  excluded.  The  same  is  true  of  the  nnfavorai)le  e.\i)frieiices  of  Miirchi- 
.son.'  who.se  stateinenls  were  based  upon  only  ](»  ca.M's.  and  who,  eertainlv 
without  reas.>n,  eoiiaiders  that  relapses,  as  a  rule,  are  inon-  .severe  than  the 
primary  attaek.s.  Further,  the  severity  of  the  rela|«-e,  and  therefore  al.-o 
iti  mortality,  vary,  like  so  many  other  features  of  tyi)hoid  fever,  undoubt- 
edly not  inconsiderably  in  accordance  with  temporal  and  local  intlueiiees. 
Under  all  eondition.s,  however,  the  mild  cases  are  far  more  fre.|ilent  than 
the  .severe,  wliich,  in  ireiu'ial,  may  b.' estimated  at  from  10  to  l,j  ])er  cent. 
We  observed  at  Hamburi.',  among  IIM'.  relapses:  Mild,  ;;t;.")— 7:'..8  |ier  cent.  ; 
moderately  .severe.  7.H— l.").ti  per  cent.  ;  .severe,  .'>.>— Kl.tl  |)er  (  eiit. 

The  duration,  the  hcis.rht,  and  the  character  of  the  fever,  as  well  as 
interciirrciit  local  disorders  are  e-p(vially  of  dcterniiiiiiitr  iiiHii.'tice  witii 
regard  to  the  chafaeter  of  the  coiir-e  and  the  tertninatioii.  A  special 
position  with  ivgard  to  prognosis  is  oc,  iipi«l  hy  the  protiticted  relapses 
attciide.1  with  irregular,  markedly  rciiiitteiit  fever,  as,  both  in  adults  and 
in  children,  they  are  at  no  time  likely  to  give  rise  to  serious  concen-. 

It  i-  an  iinport.int  (iiiestion  whether  the  chai~act.T  and  the  severity 
of  the  rela]).-e  de|.eiid  upon  those  nf  the  primary  attack.  I'lidonbtiKlly, 
as  has  Ikvii  pointed  out,  it  may  he  oh-erve*!  ill  inanv  cases  that  the 
original  character  <if  the  temperatiire-ciirve  is  repro.liK'cd  in  recrndes- 
ceticos  and  rehipses  ;  while  this  feature  is  less  marked  with  regard  to 
the  remaining  typhoid  syni])toms — the  roseohe,  the  enlargetneiit  of  the 
spleen,  and  the  diarrhea.  With  reg-.ird  to  the  tcin|)ct-.itiirc-curve,  it  has 
been  mentioned  that  it  fre-picntly  liap|.ens  that  if  the  ••iirve  exhibits  an 
intermittent  or  remittent   eharaeter  during  the  primary  attack   this   i.s 

■  Deiiti,-!,    Arijli.  >.  k'.in.  Af.'d  .   i..-.4    P..-i    ■.--.■-.-;•.•  2  .■ ,  -    -.; 


:jr)« 


■rvri/nin  irvrn. 


'C-iJi.'r-^V 


likrl\  to  l)c  rt|M';iltil  ill  till-  ivl:i|i-i'  m'  I"  liii'nliir  lAcIl  Illnrc  I'lcurly 
iiiarkid  {-!■<■  I'iu.  ■l'^!.  I'll'  ili.iriiitir  nt"  ilu'  i'i-<-  :niil  oT  the  ilcrliiic  uf 
till'  I(Mi|Hialiiic   al-ii    111  .|Uiii'l\    ic-(iiilil<'-  lliat  dlp-ciAcd  in  llir    |iiiiii:ii\ 

allarlv.        Tlii-     liM- -     (-|icci:il!y     (•■iii-|)icii(iii-     in     llic     Ic--     tV(i|iii'iiI 

variilir- ;  tin'  iii-lainc  llic  a-r,nl  al  a  ~iiiL;lc  -Imki'.  nr  the  niliral 
ilcrlliK'.  <  )iil\  rcciMllv  I  ..li-ii\iil  a  riinarkalilr  c 'iiiciiliiici'  lik(\\i~c 
with  rcL;aril  l"  tlir  i-liararic-r  .il'  ilic   rniAc  al  iIh'  Ihil^IiI  'A'  tlic    l(\rr,  in 

thai  a  I valc~irhi   t'l-mn  a  li\  |ii|-|iy  ret  ir  atlai-k  nl'  t\  |ih'iii|  liACi'  cvliiliitcil 

al-'p  ihiiiiiLr  till'  ivlaii-c,  la~tiiiir  hnt  a  U\\  day-,  lAciiin;.'  lcin|icratiii'(-  <>[ 
iiii'i'c  iliaii    II      (  . 

With  fcLfaid.  hoUiM  r.  In  llif  -lAcritN  nr  {\\,-  niildlK—  nl'  tlic  ci'iif-c 
111'  till'  irki|i-r.  a-  rni:|iairil  \\ilh  thai  i.l'  ihr  |irliiiar\  altark.  il  mn-I  l>c 
riiti-idcrcd   a-   i-tahli-lii'd  that  thi  ii-   i-    tin    ridr.       Thn-.  in  tlic  -ri|iii'iii-i' 

111'  mild    allai'k almrtixf,  aiiiiniiatiirv .  nr  alilnilr   lyjihnid    iivcf — tlic 

inn-t  -rviir  pnit fartcil  fila|i-i~  may  uciiir.  1  ImTuac,  in  auit'iincnt 
with  a  lamr  nnmiiif  nf  wrilci-  iZinn— en,  I  ji  liri-mci-tcr,  .la<'i'iiU(l, 
Sicinthal,  (liitii.  and  ntiin-),  I  may  ~lalc  llial  thi-  i-  iiiiilc  rrn|iifiit. 
Thi' diii-ali'iii  111' till' at'rlifik'  inl<T\al  inlwc-i'ii  ihr  |irimary  attack  and 
the  fcla]i-i'  appear-  in  iir  uitliniit  matrrial  inthiriiri'  npun  the  mnf-f  nl 
ihf  laltrf.  Il  i-  ni\  impiv— imi.  ImwiM  r,  tliat  fckip-c-  nrrnffiiiL'-  i  -jii- 
i'iall\-  late  iniii-i'  t'l'ciinriitiy  ]im'-ni' a  mild  loiir-i  .  'I'lir  diifatiuii  nl'  the 
rclap-c  i<,  in  the  larirc  majui'ity  nf  ••a-i-.  Irnm  -i\  tu  tlt'tccii  m-  twciily- 
(iiic  (lav-!.  rtfiiid-  (if  I'lnm  twiiity-twn  tn  twiiity-tivc  day-  air  -miu- 
what  l(—  (■iiiniiiiiii,  and  ihn-c  nf  fi-nin  twenty— i\  In  fniy  day-  are 
iili-erv.d  iiiilv  exeeptinnally.  i;ela|i-e-  i>i'  mure  than  I'mty  day-"  diira- 
tinn  1  have  iili-er\ed  in  Imt  -  in-laiiei-.  mie  nf  tnftv -three  and  annthcr 
111'   liill\  -li\  e  ila\  -. 

Von  Zieiii.-seii  iint(d  thai  liie  diiralinn  in  Ull  reiapM>  vvliieli  hr  (•iiiler|e(l 
varici  hetweeii  fi'iir  and  tliirty-live  ilay>.  In  the  nvirw  iHlmini:  ihajnrily  ^  i'tl  i 
it  varinl  helween  live  aiiii  tweiily-ime  da\<.  'I'he  tiiiiliii!.'>  nf  .laccoiiil.  « lio 
noted  the  nii.st  frei|nent  iluratinii  as  frniii  eiL'lit  In  twcii'y-iiiu'  days,  and  mir 
own  .<tatislie>  at  l.eip>ie  .  Hitl'  .  wliere  nf  L'l(>  relap.-es,  \s-2 — x{\.(\  p,.,-  ,viii. 
— liistfil  frniii  ten  ti.  tweiitv  ilavs.  are  c|iiite  siiiiilar.  An  aiialysi.s  nf  the  .fS-'> 
case.*  nf  relapse  ol.MTved  in' Hanihiirir  in  ixsi;  IssJ  iji-elnse:- liial  likewise  the 
preat  niajnrilv  nf  rasK,  namely,  lOL'— Tti.H  per  cent.  —  lasted  hctwetn  live 
and   iwemv  days. 

Itelap-es  nf  -limter  dnraiinii,  as.  fnr  in-tani'e,  less  than  -ix  days, 
are,  linwex  er.  Iiv  im  means  mre.  If  it  he  enrreetly  a-<nm(d  dial  reerii- 
de-eenee-  aiid  ivkip-e-  are  really  niily  i-epelitinii-  nl"  the  primary  attark, 
it  i-  jii-I'ti.dde  111  (■niiehide  that  inasnmeh  as  mild  and  inenmplele  |)ri- 
inarv  attacks   niav    lie   nli-ei'\ed.  almrtive   ami    inenniplete    nl.ip-e-   al>ii 

■I'l ('     .     i,..im1..?.    nC    til..,.!,    i-    Il  rlliiT    dl^i'ln-eil     1)V 


/.■/.' 7; I  i>i:s( ■i:s( ■i:s  .\m>  mi.  \ rsi.s. 


;!.')!> 


roni'wcd  I'lihir^ciiiciil  uf  tlic  -pUHii  iiml  rf;i|i|it:ii-.in(c  ul' ii.-c.,hi  ,  in  ;i-.-(i- 
ciiili'iii  willi  |«T-i-tiiii  clfvaticiii  nf  iciii|«nitiMc  I'm- (nilv  :i  Hu  (Liy~.  in 
otli(  r  caM-,  willi  a  i(a|i|i(:ir:iii<c-  .it'  tlir  Irvcr  liir  a  ~ImmM  time  altcf  an 
at'clirilc  interval  "I'  L^nalcr  "f  li— -  "Inratiun,  tlic  intcrpivlalion  l'  a 
ri'lap-c,  it'  i-oMola'  anil  -|iiinic  cnlartxi'inc  nl  arc  wanting:,  i-  tu  lie  lia-til 
(inlv  niMi!!  llir  |Mi^-iliilii\   111'  lAilniliiii:  iitlicr  I'dirilf  |p|-mi  ■(■--(-.       I  lial,  on 

arcoUMt  .'I'tlic  inailic|naiv  ot'  <iur  ilia^no-tic  niian~.  ^M-cat  <-anlion  -I M 

he  iil)-cr\  c'l  in  llii~  itinm  rli'in,  ami  tliat  in  llic  imliviilnal  ca-r  llic 
(lia"-ti"i-i>  liad  liiiifi-  111'  Icl'l  in  ilimlil,  need  -carcrly  lir  tMi|(lia-i/(il. 
'l"ran-iliir\  cIcAalinn  nl'  t(in|icraliMc,  nul  di  |icniirnt  n|><in  Im-il  iji-ca-c, 
lia-,  uiMiii  llic  -iiirLM'-liiiii  lit'  iiiirnicr,  luiii  di -iLrnatc  d  "  al'lcr-rcv  i  r." 
Siinc  lit'  till'  ca-is  in  wliidi  llii-  uniir-  ari'  rtitainly,  liy  icuMin  nl' 
tliiir  natnrr  and  dr\rlci|iincnl,  In  lif  included  anmni:  rela|t~c~,  -u  that  it 
jipcar-  mure  a|iiini|triate  t'ur  tln-i  .  instead  <il'  cni|iliiyinLr  the  nndistin<-- 
tiv(  exiirc— inn  nf  Hierincr,  In  cin|iln\  tlic  de-ii:Mali<>n  ,-liorti>l  rela|>.-e.s 
nr  '•  alinrtivc  rdapx-." 

m  (iiiite  rare  case-,  after  the  ti\tr  had  >nl(-iileil  and  the  patient  had 
fnr  davs  exhihited  -nlinnrinal  tcni|)cratMre,  I  have  ul).-ervc<l  inarke<l 
flnetnatinn-  in  the  teni]ieratnre-enrve  with  evening:  eievatimis,  nni,  hnw- 
t'Ver,  cMcedini:  .'57.5^  ('.,  a>MieiaIed  with  headache,  malaise,  i-c>tle."ne», 
and  even  >li«:lit  ^tnpor,  this  ennditinn  la^-tin^'  fiir  I'rnm  .-eveiid  days  tn  a 
wifk.  The  .-inndtanenn-  a|i]>eai-ance  nf  rusenja',  as  well  as  the  fin-ther 
eircnni~tanec  that  the  enlartrcnicnt  nf  the  -|ileen  had  nut  whnlly  <lis- 
aiipeared  after  defervescence,  liut  had  ratln'r  increas<>d  Minicwhat  diirin;; 
the  |(eriiid  nf  relative  tcMiperatnre-elevatinn,  jn>tilicd  nie  in  eunsiderini; 
these  eonditinns  aKn  as  rela|>>e>.  It  will  lie  >eeii  that  the  airret'niciit 
hetween  the  varimis  varietic-  nf  cnnise  (if  the  jprimary  attack  and  tlmse 
nf  the  relap-e  is  sn  cnniplete  that  one  may  even  speak  nt"  "afclirile 
relajwes." 

Till'  fre(|iieiicv  nf  the  ncciirrence  nt'  relapses  a|)]>ears,  as  ha»  heen 
mentiniied.  tn  varv  cnnsiderahlv  in  aeenidancc  with  tcmpimd  and  Incal 
influences  and  in  dilTereiit  e]iidemi<--.  I'rnhahly  the  ^jreut  diversity  nf 
statement  amniitr  writers  in  this  ennnectinn  is  dc|KMident  aKo  niMni 
ditlcrenees  in  concept imi.  If,  as  is  not  dnne  in  all  statistics,  the 
recrndcscciiccs  arc  separateil  from  the  relapses,  it  will  lie  fimnd  that 
the  frc<|uency  of  occurrence  of  the  latter  is,  on  the  wlmle,  in  from  G 
tn    Vl   per  cent,    nf  all  cases. 


Ill  Ix'ipsie.  we  estimnteil  the  avera;.'e  of  fourteen  years,  wliicli.  it  is  true, 
varied  consiiierahly  aiiioii!.'  themselves,  at  12  jht  cent.  ;  while  in  HaMihtirjr, 
in  the  vear  I'^.'^d-  IS^T.  14.2  per  cent,  of  rela]ises  wereohserved — unilouhtedly 
n  liitrli   iiirure,   in   eoniiiarisDu    wiili   which   the    recruih'scences  in   the  strict 


if 


.';i;ii 


TV  I  n<  III)  ii.vii:. 


-i'\\~r  l.>  |piT  ciMl.  cvliiliiliil  a  LTrnl  ili-|>ro|Kirlioii.  'I'lic  ixircrno  iIkiI 
liiin  l>i-  iiarliiil  liv  \:iriiiu>  »  rili'is  in  :ii  .  urclMinc  «illi  llu-  inl(r|inl;iliciii  of 
llii'  Icriii  i'i'l:i{iM'  Mini  Ullli  h'lii|ni|':il  Mini  Imnl  il  jlli  riini  .~  will  In-  >Ii(i\mi  Iiv 
till'  t'oliciwiiiL'  >lalt'iiii'til.  wlili'li  I  li:i\t'  iilriailv  li:i(l  |iri'{':ii'i'i|  in  jimi'I  in  llic 
ilisMTlaliiiii  (if  Sliul/..  <  )t'  nl:i|.>r>,  lln-n-  mc'iiri'i  d.  aciiuiliii;.'  In  Liml- 
wuriii,'  ill  Miiiiirli.  1.1  |n  r  iini.  ;  Miinlii-nn,  In  l.oiiddii.  .'!.(•  |icr  rciil.  ; 
liicniifr  1  I'liisclii  I  .  :l.:i  |i.r  i-iiii.  ;  lliit/.  lliinur  l>7)  1>77  ,'  I."  |,i  r 
(•(■III.  ;  Kii>.|«iii. '  ill  l>rc>^i:iii.  I.-'I  |>(  r  ccnl.:  l!i(liliin>l,'  in  /iiridi  « .-iiinincr  nf 
|.s>l^  ."i.ii  |Hr  cciil.  ;  (  liicv~iii:;('i-.'  in  /niicli.  (i.li  |.(  r  ((  lit.  :  (  iciiiardi  ~  >  ((■!- 
Icclion  li-oiu  rc|Kirl,-  nl'  i'|iiil(iiiif-  .  *<.■',  pir  ccnl,;  Slcinlliiil. '  in  l,(i|-ic 
1^77  l>s|  ,.  ~  ;,  |i,.|-  cciil.  ;  I  ,iilp(  rinci^icr."  in  I'.ii.-lc  .  1  ^ti7  I'"<71',  >.(i  |ici- 
ccnl.;  <io|li,"  in  Knl  .1>71  1  >.-*"i -.  ."».7  \<k  r  ccnl.;  riauinlcr'  I'lcnnan 
llii.-.|.iial  iif  I/iiidnn  .  !(!.'.•  |>cr  ccni.  ;  Hiilaii,'  in  I  lanilmr'j  ilN7.")i.  11,1 
|HT  ccnl.  ;  l>iii/."  Ill  .Nliinicli  .  I>7>>  I'"*'"*:!',  1 '_'.">  |ici' cent.  ;  \ nn  /,iiin.».-cii.'  in 
Miiiiicli  -  1^7'^  l"'>^l  ■,  i:!.n  |ici-  ccnl.  ;  !>(  nmllicli."  in  I'rcilnirj:,  14. H  jut 
cent..    Weil.'    in  I  Iciilcllnii-L'.  I  7. ti  per  cent. 

AlT''  .111(1  -ex  arc  ii(i|  uitli'iiit  iiitliiciicc  ii|>cii  tlio  occiirniicc  of 
l'('la|i-c-.  \\  itii  rct'(  |-ciicc  1(1  icji  .  it  lii;i\  lie  Slid  tlial  l'cla|>»c-  llli(l(iiiiit- 
c'llv  (iceiir  iiKifc  tVc(|iiciitl\  ill  \iiiijic_r  |Mr-(in~  tliaii  in  llic  later  \cai>  ol' 
lil('.  I'lil-  i~  cNJiiliitcd  with  (-|iccial  di-liiictnc--  in  llie  t\|ili(ii(l  I'cvcr 
(it'  cIlildlKM"!,  .111(1  Ik  re.  :i-  \\v  A\;\\\  ~lll'-e(|Uclltl\  -cc,  even  cMclid--  t(i 
rc|icatc(l  ril.i|i  (-. 

Aiialy.-i.- ot' .):Hi:j  ca^.  :•  al  I  laniliur.'  and  i.cin-ic  di>cliiM(l  7.'!->  rcla|'tics — 
1.')..^  |Kr  cent.  Aiiimiil:  ihc.-c.  llicrc  ncciirrcd  in  adulls  4*i.s7  ca.~c.-,  with  (I.'IO 
rcla| wi* —  1  -l.  I  |icr  ccnl.  ;  in  eliildrcii,  til .">  caMS.  w itli  id.!  relapses —  Hi..'*  per 
cent. 

Tiie  (liircrciici .-  uiili  rcirard  In  a^'c  appear  more  strikini'  in  a  studv  (if 
tile  stali.slics  nC  !,(  ip,~ic  aiiiiu.  uliicli  sIkiu  ll'.-i  per  cent,  (if  relapses  in  adults 
and   1  '.•.  1   |Kr  ceiil.  in  children. 

1  lie  (lillerencc-  arc  Ic-s  marked  uitli  icu'^ird  to  tlie  inlliierice  (if  sex 
iijxiii    the    tre(|iienc\  (i|    relap-e-.       Willi    <  iric-^iiiecr   ami    (itlier-,   1    am 

I   .\.,-:ll.   l„I.Hi,i,i,:i,l  ,   ls::l.  Mii.l   K..il..r.   //,',./.7    /).v,-.   .Miciirli.   IsTl 
"  /.    ■    .-.I.  '  /-"/"-;.   /'■--..  Znri.  Ii,   1H7:;, 

*    -SiMli-lil.   d'T  ■rvpliu-l"Ui';;uiiu   iiul'  il'T  iiii'l     Kliiiik  (Jcs  Jlcrrn  I'm!',    ./i.'iiis- 
^.Ti,      n.iitsr/i.  Ar.h.t.  U.i.     M,.l  .    Ii,l     v\i  ,   wii  .  n    wiil. 
5  I),,-  /{,■.■;,/;,;■,/■<  T;,.!,,,^.   I!n-l.-m.    IsCK. 
«  n.iitsrh.  A,.-/,./.  /,/.„.   M,,l..   li.l,   \\\i\  .  S    --".iT. 
'  /,•.,■.  ril..  S.   :J1(I. 

"  n.„i^,-h^  .I/-'.,  ;■,  Un,    M.J..  |S7:;.   |'„l.  \ii  .  S    m 
»  /'.'./..    ISSl.    l;,|.   x\\i\..  S.  :;.'.S.  /,,.,„,,     Diss. 

•»  /,...-.  rif..  p.  ms.  "  /.,„•.  nt..  p   i4i;. 

"  /....■_  .■;/..  p.  :;:i7 

"  /)..,/-,•/,.  .I,-./.,  r  /,/,,.    Mr./,.   I!.l,  wlii..  S    1117. 

"  ■  -t:iii-til;  .Ir  T;,  phiiliru,-,,,,;;  all!"  drr  iri.-.l  Kliiakd.s  Il.rrn  l'r..f  ZiuIii.<S(  n 
von  1s7'<-1s,h:>,.-  //,;,/.,  1!,1.  \\\\iii,.  .-;.  :;■_'(! 

I-    ■  r.Lcr  (!.■  TvpliUMvci.livc.'  l/.n/  .   li.l.  x\\i\   .  S,  :'.7il. 
i«  /.  .'•   r:/..  p.  :;j|. 

n    •/....    t>,it.    I.  -.    i    'ri  :  .   .1..  .     I ;,  ;    ...  .*..„/ j., .;,,  ,     i  ^.u- 


/>7'/.T/'/ >'■/>'/■>     !>/'    /.//    l/'^/>' 


mi 


ilii'lill.'<l    t.i    li.li.A.'    llial    liiiial.-    .Nliiliil    :i    -liulillv    -iv;it(r    |.iv,|i-|H,M 
(ion.       Al  liM.-l,  it  i;iii  111'   -:iiii  lliat  \\'  iliiriiiLr  mii  (  |piil.iiiic'  ;my  (litliiriiic 


'.* 


M-SI 


appears 


hi'twci'ii    the    two  sexes,  tlie  greater  imnil)er  UMially  apixairs 


M 


k  ■ 

• 

r. 

X-:.   iJ=!' 

1 

"           1 

III  I  I:iiiiI.iii-l:  iIii'  t'nllnwinir  liL'iiri"  "iTr  ol.-ir\iil 

1  >Nr,  . 
I  km;  . 


ll.'.l 


I. v.. 


.\n;il\  -1-  "f  ill      1 ,1  1 1 '-11    -i;ii  i-li''-  1  \  111  I  III-  -I  II 1 1 1,1 1-  n  -ull-  liir  ;i  niiriiluT  of 

lIlC    \c:ir>.     Illll.    "11    lIli      wiinll,    lil-i    ji.-.-    ho    llollUorlliv     cllll'i   !■(   lie.  -. 


,s 

^j^ 



\i' 

,<^  ^  ■ 

.   ,   .   , 

-^ 

'^^  ' 

f  »  f  ♦  i 

I     .T 

!  '.  !  !     !** 

.  .  ^  H 

5 

3! 

■     ' 

? 

<'^ 

1  J- 

><>. 

\ 

er. 

s 

i^ 

> 

■     '   " 

-7? 

"> 

1  cr 

> 

n 

.         -         . 

<r 

^ 

■ 

c 

> 

ro 

i^ 

^' 

<: 

.•  •  ■  ■ 

,  n 

:  ■-<: 

^^^. . 



1     ^ 

^T^^^* 

. . . , 

■    X 

:v 

n 

< 

>' 

C) 

1^  •  „   S 

.  .  .  „ 

?'i 

, . 

i* 

tr> 

..... 

ri 



1  <=> 

*■ :  ■ : 

..... 

» 

•  •  •  1  ■ 

u 

' 

CO 

, . . . 

..... 

=^ 

1;:: 

>• 

'  J- 

t^a-'  ■  ■  ■ 

er 

■    •     ""^^33 

^  • 

.... 

y 

'    ■     ■  ,J    —  ■*■■- 

-L.'          *■    •    •     ■ 

f-=      3 

O 

r:  j            « 

In  iiiii-t  i';i-c-  tlic  <li-i:i-o  liriiiiiiiitcs  with  :i  -iiioK.  rc<l"iiilc'^('(iK'i'  nr  .» 
,..].,    ..  1 i>...i I. ..     I   .   :   ..  1 ,.,.   .1        I.    ...... 


1.,.. 


.'if^*^:^,  ■  m^':/isfyWtt:>^ 


i:i:i  i;  i  /'/>'  /  \ '  7  >    \m>  mi  i  /  "</>■ 


3fi:J 


liiipiH'ii  t!i:it  ill  "111-   |i;iti.nt    niilx    r.  .timI. -.■.  lie-  ii|.  \,>  llinc  ...■.•iir,  ulul.' 

Miintli.r  i-  MlI:i.U..|   .,nly  h.\    ivl;i|.-.-.       Ilh'   ,,  .   irn  i,,-.   of  r.rpi.l.-, ■•■ 

:hiiI  r.l;i|i-"-  ii    till-  -:i |):ili(iil   i-  ii"l   iiiiii.iiiinMii.       riiclcr  -mil  cin  uiii- 

-l:ill(C-    iIm-    iv.lll.lr-r,li(r    ;il -I     :iiw:H  -    orclll-     ill    lilr    .•Mm--.-..f    ll..' 

|iriin:iiv  |><  rio.i   .,|    .1.  Ic  r\  ( -c  n,.- ;   mikI    tlicii,  alhr  :iii  iilil  liii'   |..ii."l..l 

varviii'j  Ic'iiL'-tli.  <<■ •  -''V  I'iil  nl:i|i-r-  .Mviir  (  I' in.    I-). 

I,  j,  ,|iiiir  ran  ,  iiiiii  t,,  iii\  l.ii.iu  I '(iLri'  iiowlun-  iiirin'  mc'l,  tli:"  :' 
,v,Tn.i,-.rnc,-  IMImu-  a  prMira.^t,  .1  r.  Ia|i-r--  .11  -.nr,  illv  iiM,.l,ral.l\- 
Mvnv  nr  .,  v.iv^Im  r.nv  lli.  I(  i:i|Mraliir(  ,.  ivnniir.j  f.  ll.r  iionnal 
I  ].•;,, .  |:;i,  1  1,,-)  -ii,li  a  |.ui.nt  al  tlir  iiri.;lil  i.l  -1  di  a  ivcriiil.-<viiiT 
(•oiii|.ii<'alin^'   a    ivla|i-.-,    willi    -\  in|ilcMii-   of  ili.-    niu-l    |>r.>r<>iiii<l    iiil..\i- 

ralinll.  AmilllL'  IIm  t  1"-I  rn.|llrlll  ..f  tilr  |".--illilili.-  inclltioIlCll  i-  till' 
n|«at.'(l  ivlap-r,  iImiv  .,rill-  -rliri-allN  Kill  lu..,  av.i  ral'.iv  liilVf.  l'"c.iir 
and  livr  ivla|i-(-  aiv  anion;:  llir  ■;ival'-t  r\(v|ilioii-.  I  iid.r  -ndi 
(.iiviiin-lanci-  .v.rv  individual  ivlap-.'  -iioiiid  Im'  iiio-I  nitiriiiiy 
M-nitini/i  d. 

Zi.•lll^,■.(■ll  fouii.i,  !un'in'_'  In.H  .•i,s,-s(ifly|'linl.|  Hv.r  willi  rcli'pM',  oiiiy  (1  in 
whirl,  ilnswa-  iv|,,.al.d.  In  l)iit  1  of  ll,,-.-.'  Iii'  Ixlirvi-d  liiiii.^.'lf  Ju-tili.M|, 
ahlioMLdi  iit.l  al.M.lnl.lv  .rrliiiii,  in  ii>>uiiiiiiL'  llir  ..rciirr.'nc.  c.f  ilir.'c  r.'hii  m>. 
\  limn"  the  .")•-':>  '•:!>'■>  "il'i  ri'liipsf  that  \\c  olwrv  cd  in  llic  fpidcnii<' at   liain- 

i.nri.'   tVniii    l>»xti  to    l-^^7.  in    474— !»•.»'.   ih.t  .■.•nl.  — iIht ■■  nind  Imt  imc 

icla^iw  ;  two  r.'laiws  in  14— .H.4  [)*•  r  cent.  ;  and  in  only  •")  cii-rs —<).!•  |HT(riit. 
— fiiiKHi^'  llii-  laiL'c  niiiiilHr  wi  iv  three  rehip^'s  i.li.-erved.  I  have  jvrsonally 
i.lis 'rved  fimr  relapses  in  eaeh  <>f  •_' cases  ;  aii<l  only  recently  1  iiavc  seen  a 
ca<r  in  which,  t'nihiwint:  upon  a  severe  recrndercence.  three  relapses  occurred, 
the  short.'st  of  which  was  three  weeks  in  duration.  1  w..nld  fiiHl.er  ciipha- 
si/,e  the  lint  that  the  pro|M)rtion  of  H.4  jht  cent,  of  .'ases  in  which  two 
relapses  occairred,  as  diHlos.'d  hy  the  llaiiihiirL'  statistics,  exceeds  that 
vielde.1  l>v  inv  i)revioiis  and  suKse(|Uent  experience.  1  helieve  the  (Kcur- 
reiK'e  of  such  "cases  to  he.  on  the  nverai:' ,  imich  less  freipient— 4  jkt  cent, 
would   prol.ahly   represent    the   usual   conclition.s. 

With  reteieiice  to  tlic  -evcrity  of  ivpeate<l  relapses,  this  ajiiH-ars  to 
nie  to  lie  ^r,.nerally  sli^diter  than  that  of  the  lifst  felap-e  or  of  the  firiii- 
(lescetice.  Tlie  coiitfary,  however,  is  tiol  altoptlicr  nire.  Tims,  last 
vear  I  saw  in  lotisilllatioii  a  second  extremely  severe  relapse  ot  twenty- 
six  dav>'  (iiiRltion  occur  nine  days  after  the  termination  of  the  iirst 
tiiihl  relap-e  of  only  eleven  day:-'  duration  ;  and  also  previoii-ly  I 
had  repei.tedly  enconntere<l  ea,-e-  in  wliieh  the  secontl  relapse  oxce<'<kHl 
the  Iirst  in  duration  hy  a  third  and  even  liy  halt'.  T  have  oliserved 
even  the  third  relapse  to  he  eoiisider;ihly  more  severe  and  more  pt'o- 
traete<l   than   the  two   priKcdiiifr  onc8. 


mm^ 


-   .,>  r.    J 


%<^ff-'\-rl:^ 


■:ifi^E. 


^ir 


^■}^'TK-f'-':f^\il^-^'::^r '■■!*■■ '^^■-.^v: 


/;/-.> 7: 1 ■iii:s( ■i:y<  />■  .1  a/'  1:1:1. a /'.s/x 


;uir) 


Von  /.iiiM.-.S(ti  l.as  luailf  tlic  tolluw  iiii'  inslniclivi'  tiilmlatioii  of  1  ca.-vs 
(if  iliiiilili'  nla|i.-i'  . 

IhiDil'-ii,  .i|  till-  lir>l  rt  Ini'M',  l»uraui'ii  "f  Un-  v. cuiiti  r»  lujwr 

l.-i,..l  ,^,„. 'riiiT.-  wirk-.  Kcuiimi  (iuy.-. 

S,.,,,iiil  i;i-- 'llin  .■  «,ik,-.  Kill!  Ill  ilic\-. 

'I'liinl  .  a-i' KliMii  (l:i\ -,  Si-\.iit.-,ii  ,1m\ -. 

l.',,i,illi  ,ii-.'  l-'oiirti-.  ij  ,l:i\-.  '1  «i-m\-lliiv,   iiii_\>. 

.Iii-I  a-  ill.' iMciinciicr  <il'  tlir  >iii^Mf  ivIapM'  licars  >i.iiif  rdatinii  to 
tlir  ajrc  (if  tlir  patiiiu,  -n  a^c  al-n  a|i|K'ar>  t..  play  a  role  in  n'|Hliliuii^ 
i.r  nlap-c-  and  iv,ru<i(-cin(v-.  I  liTc  al>"  vi.ni;;;  [x  r-<m>  arc  (iistinctly 
nii.ic  trc.|nintly  altiickc.l.  Tim-,  at  Hainl.iir^',  anioiifr  44  ..a-cs  of 
(liiiiiilc   i'cla|>sc.    \2   oc(  iirrcil    in    cliildnn. 

if.  in  coiicliiMon,  a  few  remarks  !«■  made  ((mccrninj:  llic  niu<lc  ,,{' 
dtvil.iitniint  c.t'  ivlai)-.-  and  nrnidi -ti  ii.c-,  it  >lionld  tir-I  !)<•  aL'ain 
Micnticiiicd  that  at  llic  jiri-cnt  day  ili<-f  arc  (.rciicraiiy  ci.nr-idcnii  td  i.c 
rcii"tiiinn-  of  tlic  [.liMiary  ni(irlii<l  |)roc<--,  .Iciicialcnt  iiimn  tlic  intntioii 
rc~|.(in-il«lc  fill-  tlii-,  and  nut  tli.'  iv-nlt  i>\'  a  new  inva-inn  liy  tyjilioid- 
liai-illi.  \Uii,  no  one  donlii-  any  lonircr  that  .viiain  inlliicnec-  wliidi 
were  foniicrly  enn-idend  a-  tlie  eau-e  of  rcla|)M-  play  oidy  tlic  part  of 
fa.'Iors  <'<.ntril)nlor\  to  iluir  development.  This  vie-  mii-t  he  adhered 
to  in  -iiiic  of  certain  h\  pcreiMtii'il  olijcviion-.  Knio.ional  <li-tniliance-, 
|iremature  menial  aelivily.  and.  amontr  injurioii-  phy-ieal  inlliieni'e-, 
iireMiatnre  LTilliiiLr  oul  of  ImiI,  ami.  .aiiove  all.  dietelii'  error-,  iinr-t  all  he 
rcirardeil  in  this  li^lil.  That  the-e  are  eontrihiitory  factor-,  however, 
mn-t  he  expri's-lv  enipha-i/i'd.  notwithstanding'-  Mnrciii-on's  views — tu 
which  ride  and  other-  airrc. — to  the  contrary,  and  even  thoiiirh  w<' 
have  as  vet  no  kiiowledjre  eciicernin<x  the  nieehaiii-m  of  their  iinliivor- 
iiMe  iiitlueiiee.  It  Would  he  a  source  of  jrrcat  daiip'r  to  the  typhoid 
patient  if  this  fnMdamcnt.'d  principle  were  ne<rle<'ted.       I  have  .d-o  noticed 

relai)-es  follow  ii]ion  a  immher  of  oilier  iiitliience-  1 ipanihle  t  >  iliet  tie 

(  rror.      Thii-.  hut    a    vear  ap'.  I  oijserved   siu'h  an  iM'curriiice  alter   the 
institution  of  treatment    for  tapeworm. 

The  patient  in  :|Mfsti(in.  a  previo\i-ly  healthy  lumse-servant  forty-three 
years  old,  wa.s  hroie.dit  to  the  clinic  civ.npl  liniiiL'  of  ^'ciieral  malaise  and 
iuK-mia,  the  diairiiosis  of  ihe  faiidaineiilal  Irouhle  heimr  indelinile.  He 
a|i|K'areil  to  he  enlirely  free  from  fever,  and  exliihited  fir  11  time,  iiot- 
>vitli.standiiii:  increa.-'ed  pnls'-frecpicney,  persistent  suhnorinal  teminTatiire 
(inoniini:.  :>t)°  ('.  :  eveniii}.'.  scarcely  oti.-")"  < '. ).  It  could  not  lie  ileteriiiined 
from  the  hi.story  whether  fever  liadexisled  dnriii!:  the  period  prior  to  admis- 
sion. .\.s  the  pallid,  considerahly  emacialed  maa  lost  over  two  |M)iinds 
diiriiij;  eiLdileen  davs'  residence  in  the  lios|iital.  in  spite  of  canfiil  luirsinL'. 
the  iliscov,  rv  of  a  Ta'iiia  nuMiiocanellaln  was  received  as  a  welcome  ihera- 
peiitie  indicalion.  On  the  third  day.  afler  siiccc-sful  Ircatment  for  llie 
t^ajH'Worm.  lln'  temperalure  hetriin  to  rise,  anil  there  t'ollowed  a  fehrile  Siale 
if  iteveiiteen  davs'  iluration,     hieli,  from  the  characler  of  the  curve,  enlarire- 


tiiinl    "f   ilic   s|il('-ii,    ni>.'(i|,r,    thill   .-icMil.-.  mill   iliazii-ri'Mctinn.    |ir(ivc(l   |o   lie 

Ivplmid.       I   ii(liiiili|('illy,  till'  |i;ilirnl    r:iiiif  uiidir  iili.--ii-\  Mlinii   iluriiii,'  iiMi\:i- 

I'M'ciii-c   rr(..ii    an   allark   uf   aiiilmhiidrv    Iv|iliiii:l    iisii-,    ami    In'   .-Dlfrrrcl    a 

rclap-r  111    ilir  |iniiiai'_\   "•■■mliliun   in  cihim  .|iuii(t  mT  l  Ik-  i  rcaiiiiciil   iiisliliili.j. 

A  i|iii-liMii  I'.ii  iiin-iv  larin-ily  .'iml  1 1  i(|iiini  I ,  ili-cii--i(|  \va~  wJicIIki- 
aiili|i\  iTlir  liialiiiiiil  III'  i\{ilinii|  r.Aii-,  ,-|ic(iall\  llial  uiili  <-n|<|  lialli-, 
caii-i'il  an  incir;i--(  in  iIk'  t'i((|iii  m  \  .il' irla|i~(-.  Manv  |ili\  >iriaM-,  ex  cii 
the  nil  1-1  iiilliii-ia-lir  aiK  urali--  nf  llm-r  niilliini-,  wcvi-  iinw  illinu'  tn  ili  — 
I'l'LTanl  tlir  |iii---ilii!i!\  111'  an  iiiilii\"i-alil  rlli  rl  in  llii-  niiMi-i!  (  I  ,ii  Imi- 
nifi-lrr.  Ilirinirr.  LimIiii.  (  iiillilaiiiiinr),  wliilc  ullinv  (  I,ri<-Iiicii-Icrn, 
\'iil;I  )  (AiiiT^-cil  a  1  ■.niiaiy  i i|ii  1111.11.  1 1'  t hr  al.iindanl  liliTalui'i'  U|iiiii  tjic 
anli|i\  I'ltii-  iiiriliiiil  111'  I  iTalniciit  lir  -imlii  i|  willi  n  Lranl  to  I'li- i|iif-liiiii, 
it  will  lie  I'liiiiiil  llial  in  iiilain  |ilari-anil  .11  rirlaiii  time-,  niiclir  iilcn- 
tirallv  llic  -aiiir  a|i|iliraliiiii  uf  liatii-lii  at  iiirnt,  the  nniiili(  r  of'  iila|i-('- 
cxliiliil-  llir  Lrriati-I  vai'ialiiin.  I  lia\i'  |icr-iinall\  liki\\i-r  iili-rr\"c(| 
>iiili  \arialili'  n-nll-  al  ilitliirnl  linn-,  wlicn  I  ciiiiilux nl  aiiliiivrft ics 
anil  lialli-  nimi'  -\ -liiiialii' ill\  llianal  |Hr-i'iil,  llial  I  am  nnaMc  t<i  cun- 
\  iiHT  ni\-ilt'  llial  till'  iiirlliuil--  in  i|ni--tiiin  rxri'l  an\'  rll'crt  in  can^iiiL' 
frla|i-r-.  I  111- i|ii.-iiiin.  1  i-ii!r-.  nil  liiin:i-r  ni-cii|iir-  tin-  [ininiiiK-nt  |iii-i- 
liiiii  it  liiriiii-rly  ijiil.  ina-iiiiii-li  a-  \m-  liavr  Liaini'il  uliirf  tlirfa|M-iitii- 
|)iiillt-    lit'   \ir\\. 

CONVALESCENCE. 

Acrmaii-  kiiiiw  li-ili;i-  nl  ilii-  |H-riiliaril ir-  ut'  tin-  |H'riii(i  nl'  cunvali-- 
ct-ni-r.  ami  ar<-iiriliiiL:ly  ut'  ii~  i-ai-i  I'lil  -ii|ii-i",i-iiiii.  i-  nut  Ir--  iniiinrlant 
than  that  ut'  tin-  i-arlirr  -la-^i-ul'  I  In- ili-cMM-.  In  acriinlain-i'  w  itii  tlic 
(-xtraiifilinai'v  \ai  iaiiility  in  tin-  -t-\-.-rit\ ,  tin-  (liiralinii,  and  tla-  >vin|i- 
liiiiialiijiiiry  ut'  ill'  ili-i-a-f.  ihi-  i-liniral  |iii-turi-  nt'  i-mn  ali-i-i-nri-  i-  al-u 
(-\tn-nirl\  \arialili  It  i-,  lic-iili-,  i--|>rriallv  intlnt-m-c-d  li\  a^'c  -fX, 
ruii-l  ilntimi,  (•iiiii|ilii-atiiin-.  and  ri-la|i-c-.  !n  i^rnrral.  it  nia\'  In-  -tati-d 
tliat  I\|iliiiiil  ti-\i  i-  i-  um-  111'  thii-i-  ariili-  inli-i-iiun-  di-i-a-o  that  iiin-l 
t'ri-i|m  iitly  iiil}i-i-  Iri'ininali-  I'alalK  ur.  at  tin-  innrlii-iun  ut'  i-iiii\  ali-M-i-nci-. 
in  ciiiniili-li-  n-Iiiraliun  In  hi-allh.  Iiualidi-ni.  -i-i|nrU.  ami  |ii'rinaii(-rit 
drli'ct-  afi-  (-iini|iai'ali\  i-l\  Ic--  rumninn  after  it  tlian  alti-f  iiian\  utlu-r 
inti-i-tiiill-  di-i-a-r-.  Imln-il.  it  rallllut  111-  dillii-d  thai  tin-  -latrnirnt 
nil-  II  inadr  li\  the  lait\'  ihat  I'li-  Ll'i'iii'l'al  i-niidil  inn  at'trr  i'ri-ii\  i-rv  ut'li-n 
liriiinii'-  I  lli-r  and  iiinic  llniiri-hiii^;'  than  |iriiir  In  I  In- di-i-a-r.  iiarticn- 
lai'iy    in    vnnn^r    |»-r-iiii-.  i-   iml    uithniit    tnnndaliiin. 


GENERAL  COURSE. 

Willi    llir   ad   i-nl    ut    riiii\  alr-iTiiri-.  tin-    lii-'jinnin;.'- ut'  wliiili    i-aii   In- 
datid  tViiin  tile  tir-l  da\   ut    |c-r-i-lciil  d(-ti-r»«'-rinrr.  tin-  runditinii  ul'llif 


(■(i.\\.\i.i:s(i:.\<-h: 


;5t)7 


|>;uii'iit  i~  cxtrt'iiiclv  variaMi',  in  accurdaiicc  witli  tlit>  course  of  tlic  antc- 

(•<il.;it    Miiack  and   iniliviiliial  cirrnnistiinco.      In  cliililic id    in  |in- 

vioii-iv  iicaltir-  vinm^'-  ailiiii>  tlio  di>cM-c  natm-ally  i-  in  p'licral  Itillowcd 
liv  -liL^dilcr  (ii-turliancc-  tliai  arc  more  rapidly  recovered  from  tlian  in 
older  indivliluai-  or  in  those  already  deliilitated  in  advance  of  the  attack. 
I  nder  ail  eirenni-lanee-,  lio\vc\er,  witli  the  onset  of  convalesceiiee 
from  >evcre  attack-  of  typhoid  tiver,  the  i)atients,  of  whatever  a^c  and 
cunstitntion,  cxh'hit  eon-iilcralile  impairment  of  the  treiieral  <'oii<lition. 
Kmaeialion  and  anemia  are  mo-t  con-i>icnon,~.  The  symptoms  of 
the  anemia  of  eoiivale-cciicc,  \\  liich  often  are  nio-t  profimixl,  are  toimd 
on  caretid  e\a!  linalioii  to  lie  d.  pendent  e^peeially  upon  alterations  in 

the  number  and  character  of  the  red  blood  corpuscles  and 

npon  vai'iations  ii'  the  pereciitat;e  ot'  hcinoLrlohin.  The  red  I  lood- 
corpiiscles  and  I,  Minjiiliin,  a-  in  the  earlier  staires.  n^nally  ])nrsne 
a  parallel  con.  ,  al-o  diirinu  coiivalc^ccnec,  Imt  not  rarely  their  curves 
<li\erjre.  TIk'  rciliiction  in  hcnio'/lohin  and  I(k1  l)lood-<'orpiisel,.s,  which 
is  likelv  to  lie  le»s  in  men  and  odieiw  j-e  rol)n>t  persons  in  general  tliaii 
iti  women  and  deliilitated  individuals,  will  have  rcai'hed  its  niaximnm  in 
the  inajoritv  ot'  ea-cs,  acconlinu'  to  ohservations.  mad(>  at  my  clinic,' 
before  the  tcrii.ination  of  the  fever,  -nl)-e(|nently  to  ri-e  slowly  ML'-aiii. 
Ia'.ss  commonly,  the  ininininm  |HTceiitaLre  of  liemoixloliin  remains 
niK'hanjrc'l  for  a  irrtain  time,  ilnrinir  the  first  part  of  the  afchrile  staps 
or  the  hemotrlohin  may  undefiro  -till  further  reduction.  It  is  intercstintr 
that  |iaticnts  who  have  liecome  markedly  anemic,  on  the  contrary, 
frc(pieutlv  exhibit  iuuiiediately  a  st<'ady  and  comparatively  rapid 
increase  in  the  percentage  of  hemoglobin.  I'hus,  Kiilncr 
ob-crvcd  In  a  ))aticnt  who  had  become  particularly  anemic  an  ii. crease 
.f  ol  jM'r  cent,  in  the  hemoi^lobin  within  six  w(H'ks,  and  in  otlicr 
paiients,  not  at  all  larcly,  an  increase  of  from  10  to  1")  per  cent,  m 
the  course  of  a  week.  Kspc<Mally  in  such  eases  of  remarkably  rapid 
rcpri«lu(*ti'in,  li  iwevcr,  have  «<■  occasionallv  obscrv<Hl  the  oecurrcnee  of 
a  stationarv'  |K'rii.d  or  even  a  tran-itory  diminution. 

The  iioi  uneommoi:  diverfxenee  in  the  relation  of  the  red  bloml-eor- 
])n-clc-  to  the  hemoglobin  that  has  lieen  mentione<l  is  referable  especially 
to  llie  time  an  1  the  circumstances  of  the  ;.'re:itcst  rednetio:.  in  ninnber. 
While  in  the  mi-jority  of  cases  the  number  of  re.1  cells  purines  a  jKU-.dlel 
coiirs<'  with  the  re<lnction  in  hemoirlobin,  it  occasionally  exhibits  a  still 
further  pro<rressive  diniimition  extendiuLT  into  the  ai'eb'-'le  |)eriod,  when 
the  hcinoi^lobin  lias  already  beti^uii  to  rise  afpiiii.      "i.,ven  at  a  later  sta;_''e, 

'   KoliiiT.    Iiini,"       '  ■     .    /..<•     rit  .    ami   Arrh     f.   /^lin.    Mrd,  Hd.  I.      Sec  ulsi.   llie 


bim 


m 


l!J?' 


M 


■Mix 


ryriioti)  i  fvi:'.:. 


a  ("ii-iiit  r;ilili-  iliiiuiiutinii  in   iiiimlicf,  wliicli  we  liavc  uh.-fiA cil   to  ivai'lt 
lialt'  a  tiiilliii'i,  ami  cxcii    incirc,  -iniiftiiiifs  oniir-. 

Ill  all  ca-i-,  cvi  II  llic  iii'iilciatcly  >cv(ii' and  iriild  cases,  the  rcstor;' 
timi  dl"  llic  ('(itiililiiiti  111'  ilic  iiliHxl  Id  liial  prc-fiil  iHliiri'  tlic  attack  lakc- 
jilaci'  lull  ^Iiiuh.  l-.vcn  al'lcr  tlic  la|'-c  iit'  seven  wi't'k-  wc  have  l.'iiiid 
that  the  li.il'inal  liinnhi  r  nf  red  hloiMl-eells  ami  the  eiil'l'c-]ii>ndiiiix  ]iel'- 
celltat;ei>t  heilliijj;l(iliili  have  nut  hcell  elllilely  n"jaine<l.  .More  (ir  le-s 
Miarke<l  dclieieiiey  in  the  iCL'^eiierat  ion  of  the  hlood  was  oli-erved  in 
ahno-t  all  ci-cs  examined  with  rcCeltiice  to  this  jioinl  at  a  time  al  which 
tlie\   could  he  sit'clv  disniis~e<l  and   con-idered  alilc  to  i-ctiirn  to  work. 

The  emaciation  of  lv|)hoid  jiatient-,  which  ha-  lieen  -ladied  hy  Sehar- 
lau,  l^cvden,  ISolkin,  and  other-,  and  sul>-ei|nenll\  with  (-|)i'eial  caic  hy 
Kohl-chiitlci' '  and  Cohin.-  i-,  in  compari-oii  with  the  duration  oi'  the 
di-easc  and  'vith  the  amount  of  wi  iijht  lo-t  in  other  acute  int'ectious  dis- 
ea-es,  not  so  (xreat  as  wouhl  he  anii(  ipaied.  It  i-  naturally  most  markwl 
in  llu'ca-csof  Ioul;'  <h:ration  and  wit.h  hiL:h  ie\cr.  hut  al-o  alter  moder- 
ate and  mild   ca-i-ihe   lo-- o|'  weii.dit    iinlicalc-  the  seri<iu-   character  of 

the  recent  infectiou  and  its  deleterious  inllucnce  upon  the  ti.--ues. 
f  ... 

All  jiaris  of  the   hodv  a|i|Mrenily  -hire  in   the  emaci.aiion — in  what 

relation  lo  one  alioihei  ha-  as  \  ct  not  lici  n  -ulUcienlly  dcleriliine<l.  The 
lo-s  in  wciiiht  is  ino-i  maiiite-t  diirini;  ihe  fehrile  jieriod.  The  rapidity 
of  this  !o-s  attains  its  maxiiniiin,  in  ca-e-  of  normal  or  more  protracted 
duration,  at  the  end  ot'thc  -ecoud,  more  trec|Ucntly  -till  in  the  c<  nr-e  of 
the  third,  we<'U  ;  I'roiu  that  lime  on  until  complete  dei'ervesceiiee  it  con- 
tinues move  -lovvlv,  not  rarelv  in  prou^re— ively  Ic— eiiiiifx  tlcj^ree.  After 
deferve-ceiicc  the  Irodily  weiL'lit  aijain  increases,  in  j^cnend  lar  more 
slowly  than  it  dceline<l  ;  naturally,  more  iapi<lly,  at  tinus  even  with 
reniarkaiile  r:i|ii<litv  alter  mild  attacks,  and  e-pecially  in  children  and 
in  yoMiiir,  pievionslv  heilthv  individual-. 

It  is  ■(  nio-t  remarkahle  tint  tha*  ha<  not  hi'en  sullicieiitly  dwelt  H[hi!1, 
if  at  all,  hy  even  carel'iil  writers,  that  in  a  considenihlc  mnnhePof  cases, 
after  eoniiilelc  deferve-cenee,  durini;  the  first,  evi'ii  during  the  .second, 
with  exceeding:  raiil\-  durinir  the  third,  wink  of  coin  ,de-cclice,  the  loss 
of  wei^'ht  siill  pidirrcsx's.  Tin-  can  he  ohserveil  lno^l  l're()Uently 
after  severe,  loni:-coniinue<l  attack-;  occasionally,  Imwever,  al.so  after 
short  attacks  ,if  mild  course.  I  li;ive,  under  -ueh  eirciinistances,  uotetl 
a  loss  of  weii.dit  ot'  as  much  as  from    l.o  to  '1  kilo-^rams  diiriiif;  the  first 


I    \:.tkm„,.n-»  S,ii^<„.hni.,  i„n     Mr,/..   N...   10:!. 

'  /('("  v't!  ilr  !),:•■,,,•  \\\\  \'\.  IHST.  Mv  iivii  i'li^crvations  ktp  ba.sHl  upcin 
llii'  «.  ■kIv  »'  i'.'lil-  "f  :ill  ni\  t\  pliMid  piitii'nr-.  tli''  il'Miii.-  \\\vm  llu'  analysis  of  VI  cubes 
II*  III''  l.i  i|ivir  ijiiiii-.  in.Mirl:ik'ii  I  \   my  a~^i<taiil,   l>r    llir-ili. 


^ 


CdW  \l  lycEScK. 


369 


week  <it"  ciilix  .(Itscciirc.  1  am  iiiial)lc  In  jzivc  a  ~ati>l'act<>rv  (  \]ihiliati<iii 
tiir  llii-  |ili<  niniiciMiii.  Sdiui' <)f  tlir  t\i(ltiicc  iiiiliratfs  tliat  iiurrastil  lo-s 
ut' water  tVoiii  llic  li--iiis  plav-  mhiic  n'l/c  in  llii-  iMiiiiu'cti.in.  I  liavc  in 
a  niirnliff  111' iii-tani<  -  nli-civi  il  jmlvuria,  iiicica-i'  in  tlic  -|)(<ilii' {j;ra\  it\' 
(if  till'  1)I(H«I,  and  a  iclativc  iiicica-c  in  tlic  niluilKT  ut"  ivd  l)l(j<Kl-c'oqni>- 
( Ic-,  in  as'ociatiiin  th.nw  itli. 

I'lio  iM~-  in  liDily-wtiuiii  in  tlii'  ciiiirsc  of  t!ic  fever  appears  to  take 
plaic  not  :ii>riiii|lv,  Inii  niiiCorniK ,  as  ( 'oliin,  l)v  llic  n-e  oi'  -nilaliii' 
apparatus,  wciirliiiiLT  tin  Ivphoiil  |ialicnt  r<'|M'at(illy  for  t\V(  Ivc  days,  lias 
dcnidn-lratcd.  Tiic  avi-rau^c  li»s  o*'  wciui't  a  day  in  a  mild,  iinconi- 
pliialt<l  case  was  (-liniaicd  by  the  same  oiiscrvcr  at  liOO  trranis.  OtluT 
writer-,  a-,  for  insianee,  l>otkin,  oliserve*!  it  to  reach  iS((ii  jrratns  and 
uiiove    i[i    M'Vere    ca-e-. 

'llie  total  Weight  wliieli  juitieiits  liave  lost  at  tlic  bcLcinninir  of  con- 
valescence is  at  times  ipiiie  alarminj.'.  1  iiave  noted  in  an  adnlt,  after 
a  x'vere,  loniT-protiaried  attack,  wiili  various  complicaiioii-,  a  re<liiction 
of  H  per  cent,  in  the  orii;inal  wci;;iit,  and  in  mild  and  n\odcrately  sevens 
ca-cs  I  have  >een  even  a- irreat  a  hi-- as  10  and  11'  ])cr-'cnt.  H'-pceti\ely. 
It  i- woriliv  ot' Mole  that  in  I'liildrcn  [  t'oii'td  the  iiiaxinHiiii  lo— of  \veit:'lit 
to  he  !•  pel  ceul.  The-e  hi^ih  tiLlui'e-  may  he  contr;i-te<l  with  soint! 
e\tremelv  low  liLinre-  collecte<|  t'rotn  a  lari:e  nnmlier  ot  oh-crvati  >ns. 
Thus,  in  mild  ca-e<  1  iiave  oh-crved  only  from  1  to  1.1  |)er  cent,  lo-,- 
of  hodv-wciu'hl,  anil  i  have  e\cn  ,-ci  ii  severe  ea>es  in  which  the  total 
lo-~  was   not    more  than   from    l.o   to  ;;   pei   cent. 

The  conditions  ih'i'inLr  con\  alesceiice  in  <l(tail  h.ive  !)een  considered 
in  various  part- of  liiis  work.  Tim-,  the  heha\ior  ot'  the  temperature 
diiri.i;;  this  perioil  was  t'ully  con-ideicd  on  pai^c-  1  Id  and  III  It  was 
<liown  that  in  almo-t  all  will-marked  cases — and  jreiicrally  the  .  .  .,Mlis- 
tiiu'tly  atiil  the  more  protractedly,  tlic  -evererthe  < mrse — thi' hcKly-tem- 
peratnri'  declined  helow  t'lc  normal  >o(iii  after  detervc-ecnce,  and  jrrad- 
iially  roVe  -ain,  reachinij;  the  prcviotis  individnal  level  oidv  after  davs 
or  week-.  It  \\:is  -ecn,  t'nrlher,  that  diirin^r  this  jiiriod  of  snlinormal 
tcmperatnrc,  a--mniiiir  a  condition  of  perfect  (piiet  on  the  part  of  the 
|)ationt,  the  daily  tliietnation-  are  >!iirlit,  often  less  marked  than  in  })er- 
fcctly  hi'althy  individnals  ;  Imt  that  they  I'come  extrcmelv  marked, 
liowever,  in  conseciiience  of  even  slight  pliy.-ical  oi-  mental  exertion. 
Tlie^c  pciMiliariiic-  of  the  ciirxc  arc  irenei-ally  -o  con-tant,  and  a])pcar  in 
.-io  typical  a  manner  after  an  a'lack  of  ordinary  course,  that  they  con>li- 
tnte  important  criteria  in  the  rccojrnitioti  oi' convale,-ccnc(>.  T  have  lonjj 
heeii  in  the  haliit  ot"  con-iderin;;;  con\  alc-cencc  alter  modems  Iv  sexcre 
and  severe  attacl.-not  com]ileteiy  c.-taMi-hed  imtil  they  aiipeaicil.  D.'ilv 
2t 


^^^>^3;i^i^fM?y' -^^ 


;!7(i 


7  1  fll'iiii  1 1  \  1 1: 


I--"" 

' 

piV 

Tf' 

w 

(■\|i(ririi<-('  trailii--  tliMt  wlicii  llicv  arc  waiiliii;;  r<la|i-(-  ami  (■"in|ilicaliiins 
arc  likely  ui  nniw. 

Till'   pulse,  a-  has    likc\\i-c    Imtm    |i(iiiiic<l    (Hit,  i-.  in  cn'ilra-t  to  tlic 
tcni|ieialiirc,  I'art  Iv  -i(i\M(l   at    llu'    luiriiiiiinLr  nl    lln-  ]»  tumI  dl'  iuii\alc— 

(•(■nee.  anil  tlicii  pinhaKlv  (Piil\    ill  -[iicial    i-n-< iihi-l    iVciiiit  iill\    i-  nla- 

tivclv -liiwi'il  in  ililciK  inili\  idiial-,  IT,  (••im  ci-cIn  ,  in  (-|i((iall\  \  ij:iu'iiii> 
!ncii.  ( iriiiralK  ,  it  i>  .-lii;lillv  nr  nidilnali  K  lull  and  It  ii-'' :  al'lcr  iiiiM 
i'a-f>  II  1-  ut' nmnial  In  c|Uciii\ ,  ami  allrr  ~c\(ri'  allacix-  an<i  in  iiiilalilc 
iiiilivitliial--  1-  lit  iri'valiT  tVi'(|ii(i.(\ — iiacliint;  in  ilic  in  ii^lilinrliiHul  ut'  1  (Ml 
in  tlif  cvciiinLT  N\  uniiii  ainl  rliililiiii  tiii|ii<nll\  -Imw  a  -till  liii^lnT  rate. 
In  achlilii'ii,  llic  |iuU<-l'ir(|ii<ii  y  i-  ixticincly  iiii«talilc.  imt  only  in  the 
-laLTi'iil'  siiliiiiirrnal  t(in|M  raliirc.  Init  al-n  nlti  n  Iiin;r  atnr  lliis.  l'|)tii 
llif  lime  lit'  iri'lliniT  np.  -liirlii  nimlal  cvt  rtinii-  m-  jiliy-iral  ili-nirl'ancM-< 
caii-r  nia'kcil  iin-ira^r  in  llic  iniiiilirr  nl'  |iiil>t-li('at-.  llii-  iin  rra-c  utltii 
raiiiillv  <li-a|i|icaiiiii.'  aiiain.  'I'lii-  [iliiniiiiifiinn  may  licniiiic  c.-iiccially 
striking' ami  tvcii  arimilly  alariuiiii;-  In  lln-  inc\|i(  ricmrcl  jiliy-iiian  ami 
the  t'rii'ml<,  wlii'ii  tile  |iatirii',  liy  na-nn  nl'  hi-  ntlnrwi-f  tavnralilc  imi- 
(liiiiiii,  lias  liccn  Lr'anttil  in'irni-~iiiii  to  i:ri  mil  nt'  In  1.  IncrcaM'  in  tlic 
nuiiiliir  ut"  piil-i -licats  ut',  mi  an  avrrai;( ,  tVuni  'JO  tu  -ii'.  ami  ]>»T.-i^triic(' 
lit'  tln'  iiii!-r-ciirvi'  at  ihi^  liiLrli  k'vcl  I'ur  -umc  tiim  —  imt  rarfly  tin'  as 
luiiU-  as  twu  wci'ks  :iim1  nii.rt — is  at  tin-  tiiiir  i|iiltc  iii-tuniary  ;  lnit  it 
:-hunl<l  III'  i-\|)rc--lv  -i:.iril  that  r\aininaliuii  ut'  tlir  heart  tlirmii:limit 
the  entire  runtinnanee  ut"  thi-  rnmliliun  ili-elu-i-  im  ^jii'cial  altera- 
tiuii. 

Till"  t'ulliiuiiiL'  two  irai'iiiL's  iiiav  serve  as  eliara  terislie  iiist.Tiices  of  this 
eliaraeter  III' till-  pulse  i'.iiii  I  he  teiii]ieraiure.  1- ij:.  M  repri -eiils  ^l|l■il  a  curve 
iluriiiL'  enii\  all  M'eiiee.  Tlie  la-e  ua.-  llial  nt'  a  hakei' -  a|i|ireiitiee.  Seven- 
teen Near-  ii!il,  w  111!  \\a-  Tree  tVnni  te\ '.r  at'ler  the  Iweiily-eiulilh  iki\  nt  llie 
liiM'ase.  ami  exliihiieij,  w  uh  a  lein|ierature-eurve  MilfriiliiiL'  helnw  the  iinrinal, 
aUn  suii  iii'iiial  |iulM-rrei|Ueiii\ .  uilh  iiHiilerale  in.-lahililv.  Iiniiieiiialelv 
alter  L"'tlinL'  n|i  there  .-el  in,  withnut  the  tein|ieratiire  lieiiiL'  inllni  iieeil 
ihereliv,  an  unn-nal  im  lease  in  the  |>ulM'-t'rei|Ueiiev.  persi-tin:;'  t'ur  .-ixleiii 
<la\s.  The  heart  at  the  -aine  lime  reiiiaiiieil  eiiin|ilelel\  niialieeteil  Imih  in 
sl/e  anil  aetinn. 

In  the  M-eiiiiil  ea-e  i  ]■'!■:.  ■!•")  i  the  tirst  t'U  i!a\>  ut'  eiinvale>eeiier  still 
exhihit  a  suhnnrnial  teiiijiei'al  nre,  uilh  at  til>t  an  imaea.-eil  |iIi1m  t'rei|neney. 
With  resturaliiin  ut'  the  hmK -tein|ieraiure  |u  tin'  ninanal  the  nuinher  ut' 
jiulse-lieals  then  >l Ilk-  ^'luiew hat.  ami  tluetuate.-  iiiuri  iiiL'  ami  e\  eiiiiiL.'  helween 
.•>0  anil  ■'^u.  (leiiinL'"  iiji  un  the  furl v--i  vent h  ilav  nt'  the  liisease  is  Mi;ain  t'ul- 
hiucil  liv  exee<-i\e  inerea-e  in  |iiil-e-l'rei|Uene\'.  with  (•iiiii|ilele  irre^Milarity  in 
it-  enr\e.  riii-  eiinilitiiiii  |ier-isl>  tiir  three  weeks  withnut  <'i)rre>|ioiiilMii' 
elevatiun  nt'  the  hinK -leni|'erature  nr  ulher  ohjeetive  ileranfremelit  n''  the 
heart,  ami    llieii    -Inwjv    :;ives   way    tn   the   t'nrmer   iinrmal    cnmliiiuiis. 

'I'lial  -iieli  an  iiniiMial  inerease  in  |.ulse-l'rei|Ueney  i  '''•  ••  ■•^litiite  the 
lieiriimiiiL'  n''  a  rehi]-e  inav  he  a^'.ain  inentimieil.  |irinei|iall\  tnr  tin'  |iur|iose 
of  intriiilm'iiiL'  a  eiirve  ihat  esiieeiallv  illii.-lrales  this  nninl  <  I-'Il'.  4t>j. 


;/<  « 


'  i).\y.\i.i:s<i:.\(f:. 


an 


fi- 
ll: 


'- -« 1 


■j^  mwiiLLML^ 


T       .?     ■    Tff 


>  wA  ■ 


f  ■< 


.^iv/, 


m 


372 


ryriiniii  1 1  vin. 


<  o.Vf  i/./..sr/..\r/;. 


M-.i 


CHANGES  IN  INDIVIDUAL  ORGANS. 
The  heart  onlv  cMcpti'iUMllv  rxliihits  altcniliiiiis  iluritij.''  conviilp-i- 
ccnce.  Now  aix'  apiiii,  Miidoiihtctllv  inuch  Ic-s  (■oiiunimly  than  (hiriiij^ 
tlie  rchrilc  period,  mvoearditis,  with  dilatation  and  eorrespoiidinir  niaiii- 
f'-.-tatiiiiis  of  eai'diac  weakness,  occurs  ;  ircnerallv,  howevci-.  the  tcriniiiation 
is  favoralde.  Kndocarditis  and  |)ericar(hti-  o.  cur  >til!  more  exccption;illy. 
IttlK-y  occur  at  all,  thcv  arc  almost  always  rct'crai)le  to  niixiMl  inf'e<'tion, 
espc<'iallv  to  a  conVplicatinL'  septicemia.  A  rc-ult  <>f  tin-  conjoint  intlii- 
ence  of  anemia  and  cardiac  weakness,  whieli   is  sDnietinie-   inanil'e--ted 


li-Jif  1 


J";r 


L-iiy 


l^i2Sf^^^*i^/ 


ji^mu^m 


■Ml 


rvrnoih  ri  vri: 


V;  '■  *r'»" 


'•  .'i 


^^A 


^  ,  , 


m 


(Imiiii:  till'  lir-t  iMirtimi  "T  llic  -Im^'c  nl'  <(iiiVMl(-ic'iiir,  i- cdi  ma  .iIh.iiI  iIii' 
aiiklc-Mii<l  llir  l(^'-,  (Hi-iiriiiiL'' <-|"<ially  in  |>i(  \i.>ii-lv  ild.ilil.ilr.l  |h  r-.m-. 

'I'lli:.     ir    |o    1h'     lli«lill_'ui>llC'i     tV'Hll     lllill      11 llilioll     \  a  r  U  I  \      "I      ■llM|,.-l(-  1 

FWcUill^'  t'f    llic    Mlliculallroll-    <-'<[\ lUl'    li-IH.    uhicll     I-    \M.li  l\    1 1 1-1  11  i  HI  I  r,l 

ov.  r  lln!  rhiiic-  1mmI\,  !iii<l  y  I  \.  u  !«•  a--...  lali'il  uilli  a.-<ili-.      <  Irii.-ii.Li  r  ' 

(>|i»'i  ially  liKiilii'ii-  llii'  (ic(airr<'iii('  of  llii.-  riiinlilicin.  ai    1  <ali  -  ^iiciilar  ..l.-i  r- 
valinll^^  liv  I.iimIcI.      'I'lic  caM'.-i  arc  Miiil  Ii>  l.i-  lull  ranly  alliU'l. 'I  \Mlliall.ii- 

iniiiiiria,  ami  iiiav  dcc-iir  fnlircly  williuiil  tlil.-  |iIiiimiiiii' t  i  in -,-ni-<  i   na^ 

no  (-atiKthi'Kiry  cxiilanaliiiii   lor  llinn.      \\r> ill\.  1   liavr  not  (il>cr\ril  liii^ 

pviiibliiiii-<iiiii]il»x  i\(t]il  ill  aN*<ii  lalimi  willi  Kiiiiciclinl  or  shortly  imlftvili'iil 
lif|ilirill.-. 

Tlic  venous  thromboses  iPiwimi-ly  <li-rriiHil  aiv  ('ii.ciiiiitcri'd 
with  rilativi'  tV(i|ilini'y  iliiriiiir  <'iiii\:il<-cfiur,  c^iMciaily  in  tlif  vein-  nl 
tlic  tliiirli  and  tlic  cl<<|i  viins  of  tlic  cahc-.  Tiny  arc  anions'  tlio-c 
.-viiilili'iii-  tliat  oltiii  |ii(iloMir  (■i.iisalr-ci'iicc  niiiliily.  l'"ciitiiiiat(ly,  liny 
arc  i-arclv  liic  M.mvc  of  fatal  ciiilioli.  Arterial  tliromlio-  -  with  -[xm- 
taiicoii>  '.M 1 1  iridic,  which  i^  cxlrciiicly  r.iri',  ha:-  liUc\vi-c  hccii  prcvioii.-ly 
considered  ( \i.  1  '17  ). 

Ill  the  lar-r  luajorily  of  ca-e-.  the  eondilioii  of  the  digestive 
organs  rapidly  returns  to  the  nornial  -",,11  after  defer\  i -et  nee.  'I  he 
liii-  and  the  toiiirne  hiiriii  to  clear  even  diiriiitr  clcfcrvc-cciiee,  >o  that 
the  tongue  is  hut  -lightly  coate<l  during  the  tir-t  few  ■lay-'  'if  eoiivale~- 
(Tiicc,  and  then  c-|iccially  in  the  middle  and  po-tcriorly,  while  the 
niaiiriiis  ani'  the  ti|>  are  free  from  fur.  After  the  toiiuiie  ha-  Idroine 
fomjiletelv  clear,  it  often  for  a  coiisider.il >le  time  appear-  thin,  ^llUlll  and 
rc<l,  and  rcinarkaMy  >miMiih. 

The  appetite,  which  alino-l  always  returns  with  (Icfervc-eencc,  often 
even  previou-lv.  liecoines  tlii-  wcll-Uiiowii  vnraci,,iis  •' aiiiictitc  of  i-oii- 
valc>cence,"  which  iiiav  he  a  -oiiree  of  gnat  ilitliciiliy  for  the  friends 
and  the  phv-ieian,  and  nadily  of  danger  tiir  a  dirohedimt  patient, 
yailnve  of  the  a]>petite  to  return  i-  (|iiiie  rare,  and  i:-  worthy  ol  ^])ecial 
con>id(  ration.  Kscept  in  ]ircvinii-ly  ill  and  ivdue.d  individual-,  this 
])licnoincnon  i-  indicative  ol'  the  latent  ]icr-istcne.  of  earlier  alterations 
or  is  a  siirn  <.f  impending  comi)licaii"ii-.  If  a-^ociat cd  with  vomiting 
and  porsi-tence  or  rccnrrcncc  of  diarrhea,  ^hlggi^h  inlc-tinal  le-ions 
iniHt  he  thoiiLdit  of,  as  >e<pi.l-  of  which  intc-tinal  hemorrhage  and 
]KTf;.rativc  pcritonili-  have  Keen  ohscrv(d,  even  at  a  late  ixriod. 
Smutimes  complete  lo--:  nf  appelile  not  ainenahle  to  any  mea-urc  gives 
ri-c  to  \\\c  rare  loiin  nf  lyplmid  marasmii-  prcvioii-ly  <ie:-crilMd.  which 
j«r-i-t>  until  ilcath  linally  occur-.  In  ca-.s  ])iir-ninL'  a  regular  and 
U'liign  coiir-c,  the  typhoid  diarrlna   is   likely  to  cea-c  Ufore  defer vcs- 


•7l*B  *■-       V 


%:^  ^'r^^^fFO^S^^^  "Z^-V.  '-.V'  ^'  ^^ 


TL*-   '*■'' 


{•iiSV  W  /  <'  7 W  /•• 


375 


ofiiii'  i-  iiini|ilcic<l.  A-  ;i  ruir,  ipi.«|i  i:iic  cHiii,ii|i  iiimi  fullciwr',  wliirh 
iM'i:i-iii|i;ill\  in:iv  Ix'  i  \  I  riim  K  nli-l  iliali  ,  ;iiiil  tliili  liiMV  1h-  il."«iH'i:iti  tl 
l\i  II     \\\\\\     clrSillii.ll     nf    |illl|«.  rMtliri'. 

Ill  nil-.'   ra-r-   (Ii-..r.|.  I-   en    tli,     |Mit  ..l'  ilic   livcT  and    the  biliary 

passages   make    llnir   a|>|Kar:iii.i-    a-    lali'    a-    lli.     |mii..(1   ..f  , \ah-- 

ccnci-.  rinv  maiiili-l  tliciii-i  K  !■-  c-iMriilly  li\  Iciiilciiii--  i)\ir  llif 
r.Mjl.m  III'  till'  Ik  II-  ami  llu'  gall-bladder,  ami  alf  ill  part  piiilialiiy 
iittiiliiilalilr    li'    iiitlaiiimalmy    iniiiiilinii-    ilr|Mti(liiil     ii|m.ii    (he    alnin-f 

( -tani     |in-iiii  r    nt'     t\  iilmi'l-liaciMi     in     tln'    i:all-lilaiiilir    ami     laiirc 

tiliiaiv  |ia"ai:i-  i.fthr  paliciil  ((Jillxrl  ami  (  iirmii.'  I  )u|(r«',- Ciiiari,^ 
Hinli-Ilir-ilil'clil  ')  i  ■■<■.■  pa-v  Jn'ii. 

Ill  till'  iiirlil  III  llii-i'  liacli'iiiilinrii-  limliii'j-.  llic  iil(-i  i\  alimw  rt'cciiliy 
liiailr  i>\-  varimi-  w  riti  i-~  nt'  the  iMTiiiicmc  nf  liiliai'v  culii-  iliiiiiiLr  cnii- 
valr-irm-r  a<i|iiiii'  -lioial  -i_riiiliiancc.  Alter  ruriiliiiiii  liail  ^iiLT^ri'tiil 
tlir  |priili  iliiiitv,  <  iillxTt  ami  (iinxlc  ami  I  >ii|ii-i- iliiiinii-tniliil  liy  illii— 
trativc  ra-i'>  tliat  tlic  iiroi'iicc  ii'^  tlic  lyiilinid-iiarillil-  i'l  tlii'  ;.i-all- 
liJaiMir  mivrlit  In-  lln'  iliinl  <aii-c  I'ur  tlif  t^iinatimi  of  laliiili.  In  liiis 
tlicv  Wile -ii|i|Mirt(Ml  c-ptiialK  li\  l>iiriiiirt.  wliu  pnsciitiil  an  aluiinlami' 
lit'  rliiiii'al  iviiliiicc,  ami  al-u  liy  Miliaii"  ami  ilamit.  I'!\p<iiinciitil 
nriHiC  fur  tlii-    lia-   aixi   liirii    i^ivni    l«y  MViial    iil>-ir\i  r-    (-<■<•    ]i.  "JJIM. 

IVnin  iiiv  iiwii  iili-cr\atiiiii-  I  auMif  ali-uliitily  with   tlic  upiiiinii  tliat 

the  tiirniatiiiii  ut'  gall-stones   is   liy  nn  tmtms  a  rare  (.iiiirnnic  in  tin- 

pcriinl    lit'  convali-iiiui  .  in    -pile   ut"  tlir   inu^t    ficcnt   cunti^Klii'liiin    liy 

(.'liantliiril."        Natiiiallv,   tiic    liiniiatinn    ut'  Lrall-~liiiics   iIims  nut   alway.-t 

niaki'  it-cIf  inaniroi  a-  early  a-  tlir  peiiinl  nt'  ri.nvalc-ccncc.      Tlic   lir-t 

attack  ut'  cdlic  ut'lcii   cnuuirli  ucciip-   mily  --uti-c.|iicntly.      'I'liat  tlii-  may 

iiccii'-  at  a  vcrv  rciimtc  imimikI  i-  -Imuii  liy   llunm  r'-'  ca-c,  in  uliicli  llic 

attack  iK'ciirrcil  ciiililccii  \cai>  at'tcr   tlic   attack    nl'  lyplmid  t'cvcr.      Tlic 

(iiic-tiiin   as   to  wlictlicr  cliiilcc\>iitis   and   ciiolclitliia~is   may  lie   induced 

liv  the  actiiiii  ut'  t\  plmid-liacilli  iiidc|Miidently  ut'  any  attack  ut"  typliuid 

I'cvcf  lia-  liccn  fai-ed  liv  ( 'ii~liinu'~ '"  ca-c  in  wliicli,  I'lnin  the  cuntciits  ut" 

tlie  LtiU-liladdcr.  a  imre  culture  ut'  lypliuid-liaeilli  wa-  nlitaincd,  ami  yet 

tlic  patient  ixa\e  nu  lii-tury  nl'  a  previnn-  attack  ut' typliuid  li\cr.      It  i-< 

mitewiirtliv    that,    on   oliUiinint:  a  caret'iil    history   ol'   jiatients   siitl'eriiiLC 

t'runi    i.i-all--lunc-,  the   t'aci    u|'  an   anticcdcnt    attack  of  lyplmid    l'c\  cr.  a 

shorter  or    luiiLrer    time    jircviuiislv,    i-    cncuiintercd    with    rcmarkahle 

frcijiicney. 

'  r,„„y,r  n-wl.  iif  /■!  ,i«,-.  ./•■  hi.^r.  ls;i()  uti.l  Is'.i;!, 

»c;„.-.  ,/,s  /,.-,/..,  i8;ii.  /.'■■.  '-if  '  A,...-.  ,-:t_ 

S  lirr   ilr  M'-l..   \H'M.  '•  l!"ll.  '/'■  hi  s...-.  ntuit    ,h    l'„r,^.   N.i\     'Jll.    1,S3C. 

'  /{;///.  mr.l  .  .luni-'J::.  1800.  »  /.'- r    '/-   M.I  .  IS'.iT 

»  Ia>c.  ctt.  ioy.,A»i.t  Jlojikinn  Husji.  Hull.,  vi.l.  U. 


MICROCOPY    RESOLUTION    TEST    CHART 

ANSI  and  ISO  TEST  CHART  No    2 


1.0 


I.I 


*"  illM 


II  2.5 

[12.2 

2.0 

1.8 


1.25    III  1.4    mil  1.6 


^     APPLIED  IKA^GE     Inc 


■■^thestef,    Ue»    f-^"         ■••bi,"J 
■16)   *ei  -  0300  -  Phone 
'16)  288  -  5989  -  Fq< 


.•'.7(i 


TYnioin  ii.vi.u. 


AiuoDir  12  (Mrit's  trc;itcil  for  L';ill-stoiics  :il  iiiv  clinic  in  recent  years.  lliere 
weic  I'l.  thus  ;lO.'.l  |ier  ci-nt.,  in  which  there  had  lieen  ;i  |irevi()iis  attack  of 
tv|'!!(!!'l  fever,  an'l  ~\ini'!'>ni>  I'f  chllh■lithia^is  liail  apinared  ileiinitelv  onlv 
snhM'i|nenlK .  (  )f  the:-e  ca.^e.^.  li'e  foUowiii'^  '1  may  he  hriellv  (U'scrihe(l  :  A 
wonian,  tliirl v-.-ix  \ears  "I'l.  wa.-  received  in  the  clinic  on  AiiLrnst  '1\.  l^i'l. 
on  aci'ount  ot'  an  attack  of  ty|ilioi(l  fever.  After  havitiL''  heen  free  from 
t'ever  for  altno.~t  t'onr  weeks,  ami  in  a  .-lati'  ol'  |ierleci  convaloccncc.  she  was 
smlilenly  sei/.eil  with  several  attack.-  of  hiliary  colic.  sncceedinLT  one  another 
at  .-^liorl  intervals,  which  niati'rially  retarile(l  recovery.  The  second  case 
occurred  in  a  woman,  thirty-ei^'hl  vears  old.  who  had.  in  May.  IMM).  passed 
throiiL'h  an  attack  of  tvphoid  fever  of  five  weeks'  dnration  at  the  clinic.  ]n 
the  i>fi:inninLr  of  the  tiillowinL'  year  an  attack  of  hiliary  colic  apjieared  for 
the  first  time  "'d  then-after  was  re|)catcd  several  times.  After  she  had 
heen  admittei  'he  hospital  in  March.   I."<!t4.  on  acconnt   <il'  severe  pain   in 

the  epitra.strinni.  liatinir  toward  the  riL'ht  half  of'  the  cIhsi  and  the  hack, 
and  associated  witi.  liiundice.  several  lari:e  irall-stones  an<l  a  niindier  of  t'rag- 
nients  were  demonstrated  in  the  stools. 

Of  :'.l  cases  <it'  cholecystitis  a.-.sociattnl  with  !,Mil--toiies  treated  at  the 
Jolitis  Hopkins  I!  isiiltal,  W  pivi'  a  history  ot'  .i  ]irevioiis  attack  of 
typlioid    lever. 

Also,  in  tlie  vast  iiiajority  of  cases  the  coiiditioii  in  tlie  respiratory 
or;r;ms,  especially  the  lungs,  returns  to  the  normal  toward  ttie  end  of 
tile  felirile  -tatc  or  dni'iiiir  the  tirst  ])(  rioil  of  convaic-ceiice.  'i'lie  linm- 
diiti-  persist  lieyoiid  the  felirile  sta^'^e  almost  solelv  in  old  or  deliilitated 
persons.  Ilvpo-tatic  conLn'Stion.  however,  if  the  patients  recovir,  may 
persist  into  the  tir-t  week  of  convalescence.  I'neiimonia  is  (piite  rare 
as  a  eonip!i<'Utioii  of  convalescence,  and  |ileiiri>v  still  more  .-o.  In 
f^reatlv  reiiiieed  individual-,  with  eiit'eeMeineiit  anil  dilatation  of  the 
heart,  jitilmonary  infarction    proliaMy  occurs  exceptionally. 

The  relation  of  tiilicrciilo-i-  to  convalescence  i-  notewortliv.  AVe 
have  seen  that  old,  previoii-ly  latent  tiilierculoiis  processes,  or  those 
frivini;  ri^e  to  sli^'lit  inanit'otations,  may  siuldeiily  ]iroirress  rajiidly 
diirini:-  convalescence:  ami  also  may  L:i\e  ri-e  to  new  tiici  of  disease  in 
the  form  ol'  ca-eoiis  piieimioiiia  or  iieneral  miliarv  tiilierciilo>is.  For- 
tunately, it  is  rare  fur  the  n-idiia  aint  s  i|Uel-  ot'  typhoid  atl'ect'ons  of 
the  larynx  to  complicate  convale-ceiice.  cither  in  the  form  ol"  sini|)h> 
ulceration  of  the  miicoii-  inemlirane  or  in  that  of'  perichondritic  proce-ses 
!ind  iiecro-i-  of  cartil.aLi'c  l*aralv-is  of  the  vocal  cord-  has  lieeti  excep- 
tioiiallv  oli-crved.  A-  ha-  heen  pointed  out.  iiio-t  o|'  the  le-ions  of  the 
larynx  iiientione<l  occur  in  the  -cc'iid  h.dl'  (■!'  flu-  f'elirih'  period.  It 
.appears   c|uile    rare    fir    them  to  develop  a-  late  a-  the    period  of'  conva- 

le-ceiice. 

The  alteration-  and  symptom-  referalile  ti.  the  nervOUS  System, 
likewise,  irciierally  improve   rapidly   diiriiiL:  convalescence,  in   the   o'reat 


coyvAi.i:sri:ycE. 


377 


iiiMJoi-itv  <<l'  insfcinco~.  Previously  lic;iltliy,  iint  liystorio  or  luunistlicnic, 
iHM-sdii-  :ii'<niirc  a  |Hiir(t'ul,  ipiitc  iimtciitrd  t'niliii'  nf  miiwl  soon  ;iikT 
(icfirvoswnco.  Al  lim-t,  tliey  di>trc.-i-  tlii'iiiMlviv  wilii  de-ins  witli 
rci'crcnoc  to  tiM.il,  wliicli  may  not  ho  tiiitiil<ii,  ami  ovcrfsiiiiiatr  tiicir 
I'liiirtioiuil  aliility,  and  in  <-oii-cc|iirnce  arc  dc-iroii^  ol'  ^i.ttjiiM  ,,iit  ui 
lied  tiio  oariv  and  of  re>iindnL:  llieir  worii.  Women  and  (iei)ilitatitl 
persons  remain  irloomv,  irritahle,  and  even  liypoelmndriacal  dtirinir  the 
fir.-t  period.  Ciiil(h-eii  also  are  likely  to  he  ill-tempere<l  and  laerimosc 
at  tir^t. 

That  mental  distnrhances,  espiM-i  diy  isolatcnl  delusions,  may  persist 
for  a  eonsiderahle  time,  and  even  liir  heynnil  the  |)eriod  of  eonvales- 
cenee,_  has  heen  previoiish  |ioint.'d,  out  and  ilhi-trative  instances  liave 
been  cited.  However,  it  slionld  he  noted  that  these  disturhance-  i>cr- 
sist  from  the  felirile  period  far  mon;  fretpiently  than  they  ari>e  durinj^ 
convalescence. 

Headaelie,  which  plays  no  incon-iderahle  n',/,-  durinir  the  initial 
period  of  tiie  attack  of  typhoiil  fever,  is  (piitc  nire  durinir  convalescence. 
It  the  ])ationt  is  not  a  person  who  for  a  loiii:  time  preecdinir  the  attack 
had  siitfercd  hahitnally  from  headache,  tlie  appeanmee  of  this  symi)tom 
durin<5  ctmvaleseence  >iionld  he  viewed  with  distrust.  Not  rarely  com- 
plications arc  conci'ale<l  hehind  it,  as,  for  instance,  racninL'cal  inHani- 
miition  secondarv'  to  middle-ear  disease,  sinus-thromh(»si<,  and  even 
cerehi-al  abscess,  (inite  exee])tionally  followinir  ty]>hoid  fever  there 
mav  also  he  headache,  <'ontinuin>f  f  >r  years,  or  even  ihronirhout  life, 
withont   demon-trahlc  oriranic    lesion. 

Focal  di>ea-e  of  the  brain.  juMvistitiij:  from  the  febrile  period  into 
convaleseence,  and  evci  beyond  it,  may.  of  coiir-e,  occur.  In  thi-  con- 
nection monoplejria  and  liemiple>ria,  a))hasic  states,  and  multiple  sclerosis 
should  be  borne  in  mind.  Among  the  sjiinal  affections  and  disorders 
()f  the  peripheral  nerves,  ataxia  and  pseudo-ataxia,  and  the  compani- 
tivclv  fnnpient  distressin;;  nouralirie  disturbances,  especially  in  the  toes 
and  the  lii'cls,  slioidd  be  borne  in  mind. 

Anion','  the  organs  of  special  sense,  the  ear  almost  solely  plays  any 
rn/r.  Atfections  of  the  middle  eiir,  with  perforation  of  the  tym[)anie 
nunibi-ane  and  suppuration,  may  mal<c  the  clinical  picture  of  convrdes- 
cenc(M[uite  serious  ;  and,  if  lilt'  i-  |)rc-ervtHl,  may  give  ri-e  to  permanent 
impairment  of  hearing.  As  serious  diseases  of  the  eye<  are  lar  less 
eonimon  in  the  course  of  typhoid  fever  than  are  di<ea-e-  of  the  auditrvry 
ajiparatn-,  -o  during  con\alc~cence  are  they  but  nirely  likely  to  rci|uire 
the  intervention  of  the  pliy-ician.      Photophobia   during  the  first  wwk 


;!7.s 


ryi'iinu)  n:vi:n. 


Ilia 


P!' ;^M 


\W' 


SS^:. 


itri 


111'  cnnv  ;il('-i'cn<'c  in  |Kili('Ml,^  wlin  ai'c  ~cii-ilivi>  in  otlicr  v<v-]H'ci>  is 
(•ii!ii]i:ira!i\ fly    the   iiiu-t    t'rcijUi'iil    'H'lilar  -yiiip!"!!!. 

Mdic  rni|iitnt  tliMii  iiti\(>ii>  cli~iiiil(  r-  diiriiii:  tlic  luriod  of  con- 
v;il(-((ii(C  arc  altcniticiMs  in  muscles,  bones,  and  joints.  In  {\\\< 
ciiniicilidn  till'  Mit'trninir  |)riM'(---c.-,  the  lacrralinn-,  and  tlic  licinor- 
rliaLic-  into  the  -uli-lanrc  nt'  tlic  niii-cic-  ^irllll!d  lie  lidrnc  in  mind. 
Aitrntidn  lia<  liicn  callrd  rcct'iitly  in  a  nnnd)cr  ol'  ((ininuinicaticins  liv 
.-•ni'iicnn^  111  till'  Iv])liiiidal  li-imis  ot"  tlic  Imnr-  and  |i(rio-tfiiin.  I  lia\t' 
r<'|icali'dlv  uli-crvi'd  |irri()-lili-  with  .-ci'ondai'v  nci  rii~i-,  a-  well  a-  o.-tcu- 
invi'liti-,  appeal'  dnriii!^  convali-ii'iirc,  and  in'oion^-  tliis  iindiilv.  Such 
Ic^idii-  may  eventually  rei|nire  (ipiTatix  c  intervention,  .-e(|iii'-lrot(iiny, 
anil  the  like,  and  may  Lnve  ri-e  to  even  |ieriiiaiient  im|i,'ili'inent  nt" 
t'lmetiiin  of  the  |iart-  invulved.  Less  eomiiion,  lint  i'S|iecially  wurthy 
iit'menlii)n  nii  aeeunnt  i it' their  eiinse(|iienees,  are  inflammatury  disnrders 
III'  the  jiiint^  ari-inir  diiriiiLr  ennvale-eeiice.  Itiiser'  had  already  called 
attention    t(i   -ilch     involvement    ut'  the    hiji-iiiint. 

A  more  c\ti'ii<led  discii--iiin  ot'  this  siilijcct  u  ill  lie  I'onnd  in  the 
sei'tion  nn   l'athiiliiL.''v,  p.  ST. 

( )l'alieratiiin--  in  the  urinary  organs  there  i^  not  much  to  say.  The 
polviiria  ot'  ennxaleseent-,  which  in  itsclt'  is  of  little  siLrnilicaiice,  and 
oidv  with  exce]itional  rarity  c<in-titutes  the  inception  of  dialietes  insipi- 
dii-,  has  heen  mcntioneil.  T'elirile  alhuniiiuiria  |iersi-ts  liut  rarely  to 
the  lieirinniiii.'-  of  cdnvale-cencc  ;  the  altiTatidiis  in  the  urine  catise<l  hy 
actnal  tvplmid  nephritic,  however,  may  jiersist  lieyimd  the  jieriod  of 
ciiiivalesi'iMice.  Forinnatelv,  it  i-<  an  oxceptiotial  occurrence,  csjRH'ially  in 
compari-on  with  other  acute  iid'ectious  diseases,  a-,  tor  instance,  scarlet 
[\\rr,  diphtheria,  and  necmtic  antrina,  fur  chronic  nejihritis  to  develui) 
friim  the  acute.  When  the  le-ioiis  of  the  kidney  actually  ]icrsi-t  lieyoiid 
the  period  iif  ciin\alc-cence,  liii|H'  <if  their  siili-idcncc  may  still  he  enter- 
tained t'nr  months  and  even  a  year  ;  and  w  hen  snhsidenec  does  no:  take 
place  within  \\r<  time,  a  loniz-continueil,  imt  not  violent,  eourse  may 
with    priilialiilit\-    lie    ]ire(licieil. 

In  women  vc~ictil  catarrh  ot'  -lii:lit  virnlciicc  may  occa-ionally  occur 
toward  tl nd  o|'  the  liin-ilc  -taLi'e.  or  niav  lir-t  appear  diiriiiL:  conva- 
lescence. In  nicii  tlii-  i-  lAtri-melv  niro  and  then  ainio.-t  aluay.-  a-  a 
re-ult    of'  cai'cli—    iiiiplox  iiiciit    of  the   catheter. 

I  lowexcr,  the  i\|ilioid-liacilli  niav  pcr-i-t  in  the  urine  for  months 
.and  even  liir  year-  and  may  induce  a  chronic  firm  ot'  cystiti-  (^.-eo 
p.    lltM). 

With  rci:ard  t,.  the  genital  functions,  it  -Imuld  fc  mentioned 
'  ll.'lwiu.   lii'iii.j^   Diss..   Maii.uri;.   1>-.'.';-   citi-J  l>y  (.rii;--in;;iT. 


(■(i\v.\f.i:sci:xrf:. 


379 


tliat  |)rc;.'iianl  wimicii,  :it'i.  r  li;i\  iii^'-  Micfcssfiilly  i);i-<c<l  tliniii;;li  llic 
iilirilc  r^VAirv,  ni)t  nii'clv  almrt  or  aic  (l(Ti\rrc<l  jitiiiiutiinly  iliiriii;.' 
ci)iival(>s('('iH'('. 

Mcnsiiiiatii'ii  rciiini-.  in  a  iiii>-i  %  ariaKli'  manner.  In  \iLriiriius,  ri)l»u.-t 
Wdnii'ii,  liiii,  Mnl'iirtiinairly,  xiniciiniis  al-o  in  already  liiL'lily  aiicrnir 
one.-,  it  ()cca>iiinally  rctni-ns  mmiu  al'tir  ilct'crvtx'fncc — in  -mall  amnnni, 
a-  a  rule,  for  the  tii-t  liw  tinic<  ;  occa-iniially,  lidWcvir,  mi  |>riit'ii^(ly 
that  tlic  (lalicnt  i-  tlicrchy  -criiiii-ly  injnrcd  anil  ntanlcil  i'l  liic 
|ir(p;.f|'fs-!  ti)\var'(l  recovery,  in  utlier  ea>e-,  on  tlie  contrary,  without 
>I)ecial  can-cs  heiii^-  disi-ovei'aliie  therel'oi',  nien-truation  lonjr  remains 
al)-ent,  even  liir  nianv  month-  lieyond  convale-eencc.  Also,  inen-tnial 
iiiolirnina  |)revion-ly  ikjI  noticealde  ai'e  con-idereil  liy  women,  at  times 
eorivctlv,  as  a  -ccjuel  of  the  attack  of  typhoid  lever.  I'ci  i-iiterino 
hematoceli',  de-erihed  hv  Trous-ean,  and  homatometra,  whicli  occurs 
rarelv,  with  it- often  oli-tinate  se<(iiels,  hav<' licen  referred  to  (p.  liKI). 
Sometimes  the  re-i<lua  of  intlanimatioii  <■('  the  jrlaiids  of  Bartholin  and 
deenhital  nlci  rs  ot'  the  labia  and  tiie  vulva  cau-e  much  di-eumlort 
during  convalocence. 

In  men.  at  the  period  of  adole-cence,  erection-  airain  occur  dnriiiij 
earlv  (•onvale-cenee,  and  in  aildition  not  rarely  di-lie— iiijx  enervating 
jiollutions.  I>'or  some  patients  they  <'onstitiUe  dii-cctly  a  disturbini;; 
complit'ation  at  this  time.  Orchitis  and  epididymitis  are,  as  is  well 
known,  ([iiite  rare,  and  then  are  iriTierally  all'ections  of  the  la-t  |)art  of 
the  febrile  staire.      Ainoni,''  (i  cases  imiU'r  my  personal  observation,   2 

developed    after    deferve-cenee. 

Till'  skin  i-  i^eiierally  dry  at  the  lH'<riniiiiij^  of  convaloscence,  and 
when  it  lias  been  indurated  ami  thickened,  particularly  on  the  hands 
and  the  teet,  it  is  de-(|iiainated  at  this  time  in  -hred-  ol' jz;reater  or  lesser 
size.  On  the  trunk,  and  e-pecially  on  the  abdomen,  iiraimy  de-ipia- 
niaii.iU  of  the  epi<lei'niis  ot'ten  occurs  if  there  has  be<ii  an  exteii-ive 
sudamiual  eruption  durimj;  the  iibrik-  stairc  'i'his  de-i|uamatiou  at 
time-  lieconics  ro  markid,  pai'ticularly  in  children,  that  if  the  |iatients 
tlr-t  come  under  ol)-ervat ion  duriui;-  ci  nvale-cenee,  -erioiis  doubt  may 
ari-e  as  to  the  nature  of  tlic  antecedent  di-ease.  Multiple  furiuiculo-is, 
which  tbrinerlv  con-tituted  -o  di-trcssiui;-  a  disturbance  of  couvale-cenee 
Ibr  patient  and  phy-ician  alike,  is,  Ibrimiatelv,  at  tli"  pre-i'iit  day  far 
less  conunon  than  at  the  time  when  nnnece--arily  t're<|Uent  and  too  cukl 
btiths  were  prescribed.  Px'd-sores  also  liy  no  means  jilay  tlie  same  rn/i' 
a-  tbrmerlv.  With  rcLrard  to  the  coiiditiou  of  the  hair  and  tlie  nails 
duriiit;  coiivalescciK'e,  reterence  may  be  made  to  jiaps  l.'.'J  an<l  ]•''•'!. 


IL 


*?^ 


'"  ■  r  . 


; '.  -,jj-. 


380  TYrii')ii)  lEvr.n. 

THE  DURATION  OF  CONVALESCENCE. 

C<iiiv:ilr-(('Mrc,  wlii  licL'iiis  witli  tlic  «lii,-c  ol'  tlic  iMirilc  period, 
(aiiiiiit  liavr  ii~  tulal  iiuratinii  acciiraiily  cstiiiiatiil,  lictiiii^o  (Icliniic 
(  ritciia  i>t'  its  trniiiiiatiuM  tammt  lie  t-tal)li>luil.  In  triinnil  it  may  lie 
ciiii-iilcrcd  a-  ciiiicil  wWw  liir  iiiitiiiiuii  lias  Ikcii  mi  tin'  im|ii-iivcil  tiiat 
till'  l>i»l\-\v(ii;lit  a|>|ini.\iiii:itr-  it-  |ir<viiiu--  level,  ami  tlie  individual 
i-  tVre  I'l'dni  cuMiidaints  and  i-  ws^m  capalile  dt'  re~iiniinii:  lii»  wipi'k.  It' 
tli(;  time  ineinde<l  in  lliis  pe.  ind  he  ()l)<erved  ii:  a  lafLTe  nurnlier  nt" 
ea-e-.  il-  lenutli  will  lie  t'nimd  to  lie  exi reuK'lv  vai'iaiile.  An  iMi]i(irtant 
)•''/''  i>  jilaveil  in  tiii-  •■nniie<'ti"n,  natni'alK',  liv  tiii'  M'Verilv  dl"  tlie  anle- 
eedent  di-ea,-e,  hut  a'^e,  sex,  con.-tiuitiiin,  anil  eiitu|ilieatiiins  are  also  ol" 
siicii  im|)ortani'e  tliat  ea-es  oi-iirinally  df  milil  cdiii-M'  may  lie  attended, 
in  eonse<[iienee  of  the  intluenee  ot'  tliise  |]i(I(ir>,  with  extremely  ](ro- 
traeted  eonvaleseeiiee.  \\'e  may  recall,  in  this  eomieetidn,  the  eoiii'st' 
dt'  tvjihdid  fe\er  ii>  the  au't'd,  and  the  al'ehrile  and  slow  f'o'Tiis.  The 
jirohalile  duration  is,  naturally,  liiyund  the  r.^itre  of  e-timation,  in  the 
iireseiiee  ol'  eom|ili(atidns  and  sei|Uels,  as  well  as  in  caMS  attended  with 
ri'enideseeiiees  and  rela|i-e-.  A]iait,  liowpver,  from  individual  condi- 
tions, extraiicdus  eireiim-tanee<  -till  diHieult  of"  appreeiation  at  the 
piixnt  dav  mav  in  the  eoiiive  of  certain  epi<lemies  ean^e  eonvalcsceiice 
in  jxi'iicral  to  be  ])rotraete<l.  If  it  he  de-ired  to  expre>-  the  duration  ut" 
c'diivale-cenco  detinitely  in  tiirures,  a  period  ot'  t'rom  two  to  three  weeks, 
after  \vell-markt>d,  nncon)plieated  ease-,  may  lie  eon.-idered  as  short  and 
favorable.  Searei'lv  le-s  eoiiimon,  and  i|nite  u-ual  after  severe  attacks, 
is  a  duration  of  t'roiii  four  to  five  week-.  In  not  a  t'ew  cases  convales- 
cence mav  be  protraeted  even  lieyond  thi-  period,  and  (X'casionally  is 
of  extraordinarv  duration,  particularly  in  rclap-ii.j;-,  slo\T,  or  inafantic 
ca^-c-. 

Ill  l>ci|)sic  (HerL')!!!  avera.'c  (luraticn  of  convalescence  w.is :  I'p  to 
tweiitv  dav.s  iii  5")  per  cent,  of  all  cases;  twenty  to  forty  days,  in  89  per 
cent.  ;  forty  to  sixty  days  am!    iVcr.  in  ."J.H  per  cent. 

An  anah>is  of  ■  (I'm;  ascs  ihiriie.'-  the  scvi  re  eiii<leniic  at  Ilamburtr  in 
iSMti-lS.sT  iliscl(,se(l  a  duration  it'  u])  to  twenty  days  in  :'>!'.•  cases — 10.3 
per  cent.  ;  In'twccn  twciity-oii.  and  forty  days  in  2447  cases — 711  j)er  cent.  ; 
between  fortv-onc  and  sixiv  dn\s  ii\  I'll  cases — ti.'H  per  cent.  ;  sixty-one  days 
and  over  in  1  !'.<  caser- — .'!.,s  jur  cent. 

THE  TOTAL  DURATION  OF  THE  DISEASE. 

It  will  be  ino-t  appri|ii-i:it<'  .it  thi-  place  to  Tiiake  some  additional 
remarks  concerninLT  the  total  dur:iiioii  ot'  the  di  "a-e,  which,  naturally, 
i  1.  hides  both  that  of  the  I'cbrih-  period  ami  that  of  c .iivaleo'cnce. 
in   the  lir-t   ]ilace,  .-ome  stateincnts  may  be  aildcd  with  regard  to  the 


TiiF  TOTAL  DrniTfoy  or  tiii:  i<isi:.isi:. 


381 


anil  I 

is  fsi)eria 


(InrMtion   of  tlu'  tllirilc  >t:iLa'.      It  is  iiiccmipaniiily  iiKPtv  ditlicjilt  \n  j^ivo 
an  avcm^ro  li<,'nrc  for  tiiis  staiji'   in   tvplioitl   than  in  tlio  aciui'  inil'ctiotis 
diseases  tliat    jyur-iie   a   far  nioif  .•yi-lic  course,  as,  for  in-lance,  iiiirinous 
jmeiiMioiiia,  ivpiiii-  fever,    relaji^in^'    fever,  and    tiie   acute   exaiitlieniala. 
While  in  the  latter  liie  fever  is   r;on!ined  to  siiarply  defined   titne-iiniit-, 
the  fehrih'  ^tal:e  of  typhoid  fever  is,  as  iia.-  i.eeii  seen,  of  inhnilely  varia- 
l)le  course  and  ihiratioii,  from  cases  tiiat   ixionie  afel)rilc  in  tiie  course 
of  a  i\\v  (lavs,  to  tiiose  lu.-tin^'  many  \\eel<-.      In  addition,  the  propor- 
tionate fre(|Uencv  of  the  niildu-t  cases,  the  moderately  severe,  the  severe-t, 
and   tho-e   of  lon;_'e-t  dunition,  is  extremely  variable  at  dilfirent  times 
n  dilV.reiit   pla<e-.      The  freipieney  of  the  mild  and   abortive  ca^es 
.-  variable.      Thi.s  is   not  even   proportional — as   must  ajraiu 
be  especiallv  einplia<ize<l — to  the  severity  or  the  mildness  of  the  cli;ir- 
acter  of   the   individual    epidemic    in    other    ropects.       Thus,     I    have 
oneounterc<l  perio<ls   in  which,  in   spite  of  a  relatively  larj.a'  number  of 
mild  and  al)breviat((l  cases,  the  mortality  was  (piite  con-iderable,  because 
the  severe  well-marked   ea-es    pursued   an  especially  unfavorable  course 
under  the  controllinjr  iutinc-ice  of  the   predoniinatiuu'-  varieties  of  course 
and    complications.      If  the    indeterminate    mild   and   abbreviated    cases 
he  left  out  of  the  count,  and  an  attempt  is  made  to  determine  the  duni- 
tion of  the  well-marked   moderately  severe   and   severe   cas.'s  only,  the 
averaL'O  duration  of  the  febrile  jieriod  will  be  found  to  be  iVom  two  and 
a  half  to  live  weeks,  but  this   may  be  extended   to  six  weeks  and  eveu 
beyond,  even  in  the  absence  of  complications. 

It  niav  l)e  in.-.tnietive  to  form  an  idea  of  the  variable  duration  of  all 
the  eases  in  a  sinLfle  epideiiiic,  tile  mild  and  the  severe  tuLrethe".  Thus,  an 
analysis  of  the  cases  at  llainbury;  in  the  year  ISSti-lS.ST  yielded  the  f<il- 
lowiiiir  residts*:  The  duration  of  the  febrile  period  was  observed  to  he  u|i  to 
tweiitv-one  days  in  i;()40  eases — oT.  1  per  ei-nt.  ;  from  twenty-two  to  thirty- 
threedavs  in  111-"^  ciises — ^:!1.:J  per  cent.;  thirty-three  days  ami  over  in 
417  cases — 11.1)  i)er  cent.  In  9  instances  the  duration  was  more  than  sixty 
davs.  and  the  lonu'i  st  was  seventy-iive  days. 

With  reirard  to  the  conditions  responsible  for  the  durafinn  of  the 
fever,  as  little  i-  known  as  with  rcirard  to  the  circumstances  respon-ible 
for  the  various  firms  in  Lrcneral.  Even  the  ^'cnend  factors  are  but  little 
known.  The  iidluence  of  ;iire,  however,  is  the  most  conspicuous  of 
these  factors.  We  have  already  seen  that  the  febrile  staire  in  chiMren 
is  in  ureiicral  diorler  than  that  in  adult-^,  and  that  durinsr  cliildhocMl 
itself  this  is  true  of  the  <'ai-l\-  perio<ls  in  Ln'cater  deirree  than  of  lh(>  later. 
'I'he  course  of  the  di-ea-e  i-  es|)ecially  prolouired  at'tei-  the  fortieth  year 
and  in  ■iM  a.xe. 

An  examination  of  our  statistics  at  IIa'i\i)urL'  with  regard  to  tlie  duration 


-, 


ft'  '■■ 


;;s: 


TYrii'iin  ii:vi:i:. 


(if  the  t'cvtr  III  the  varic>u>  pcrlixl.-  n|'  lil'c  .  (-liiiiiilcil  with  n'frroMci'  lii  tlu' 
iiiirrili<r  dl'  ca^cs  inlniitloil  ;il  tlio  \Mriiiii»  :iL''i-'-l'i'riiiil>  \ii-liliil  llic  rnlli.«iiiL' 
I■^•.-ull^  • 


AOB. 


-  I 

■     -1  vi  ;ir- 

.     .     .                  '.ijii 

1 11 

'■  I 

.   In      ■■ 

Till 

is.il 

1 1  1 

.11- 

t;n  s 

■.'.'..7 

1..  t 

p  L'O       ■  • 

.   .             .-..;  I 

:;•-'.."> 

L'l    1 

■  'J  '       ■  ■               ... 

.   .                •'(  ■'• 

:;i.j 

,  ;;ti      ■  ■             ... 

.-.  1    H 

:!l.o 

1  III       ■         .... 

III 

;!::,:! 

11    t 

.   1.-,      ■• 

.     .                   11. U               1 

L'll.t! 

I'liralji  11  nf  f.  l.ril'    I"  ri'"I, 
I  J.  iM  .i  ij.iy-.  I-' r'tiii  jj  tn  :;.Ti|a\>.       :«:ilii\  -  jumI  "M-r. 


L'  II 

II. K 

II..-, 

'.I.S 

1  ■_',  I 
II. '.I 

L':;.4 


l.ii 


This  t:ilii»'  nmcluik'.-  with  the  iiinv-tlt'lli  \iar,  :i<  llu'  imiulicr  nt'  cmscs 
ailiiiillcil  at  lali  r  aLT-iH'rimls  i>  naliirallv  .-n  .-iiiall  iliat  llii'V  do  not  aii|icar 
availalilf  tor  >iali.-rKal  iiur|iii>(s. 

'The  (litlii'uIlN  lit'  olitaiiiiiiL'' a  u'liirral  nuiiMriral  iilra  a-  tn  tlir  tutal 
(lui'atiuii  'it'  tlic  ili-caM' — tliat  i-,  tVnin  tlic  licij-iiniiiiL'  "I  tlic  i'cvi  r  tn  the 
tcnniiialiiiii  nl  ciiivali'-cciK'c — lucd  imt,  in  \\v\\  nt' tlic  fiirc'/iiiiiir.  atraiM 
'ic  ])iiinl(il  nut.  XcviTllii'li --,  a  trw  ,-uui:<'>t Im'  t'lLinri'-  may  lie  ii>ct'iil. 
l'"iir  Wfll-iiiarktil  I'a-i.'-:  ot'  t_v|iliiii(l  ii'vcr  I  -Imiilil  cnii-idci'  tlir  a\  (ra^c 
liiifalimi  iVoiii  tlic  licii-iniiiiiL''  tn  tlic  jicriml  nt'  ili-cliarijrc  ami  fc^Idralimi 
lit'  the  capaliility  t'nr  wnrk  a.-  t'nuii  five  tn  ten  wccU-.  Only  tlic  al\|ii- 
cal  and  tlic  milder  ca.-c-  nm  their  eniir-c  wiiliiii  a  slun'ici-  pciind. 
Nut  a  tew  cases,  linwcxcr.  |)ci>i-t  till'  a  cnii>ideralilc  time  licymid  tlic 
avirau'c  pcrind  ~tatc<l.  I  lia\c  (ili-crvcd  cMrcnic  ca-c-,  wliidi.  iicmt- 
tliele-s.  Ie|-iiiiliatc(i  in  eiiiii]ilelc  I'ccnvcry,  la-t  n|i  tn  twenty  weeks, 
e.\ce]itinnullv  t'nr  a  lialt'-vear,  and  even  Iniiiicr.  In  the  laliir  cases,  nt" 
cnnr-e,  the  jtrolntiiratinn  was  dc|iciideiit  iipnii  the  iiilluenee  of  local 
li--inns   and    njinn    I'cci-iidc-cence-   and    rela|i-e<. 

Ot'iiiiirc  than  .'IlHIO  ran  full  v  -tuilieil  ea>es  in  the  e|iiiieinie  at  I  Fainhuri.'. 
7'J..")  |ier  iM'iit.  Iinil  a  tntal  iluraliiin  nt'  trniii  tliirly-oiie  in  eii:hty  days.  Tliu 
iiverajre  iliiratiiMi  of  all  the  analy/.cil  eases  wa.s  tifly-tivt'  days. 

FATAL  TERMINATION.     PROGNOSIS. 

Witli  rcLnird  In  the  prnirnn-i-  of  the  iiiin-t;ilal  ca  — ,  aliiiiidant  refer- 
oiices  have  Keen  made  at  many  ])arl-  nf  tlii~  wnrk,  -n  that  the  tiillnwiiiir 
sc<'linn  will  enntine  il-elf  alnin-t  exehi-ively  111  the  t:il;il  tii-minatinn  and 
tile  related  [irnirllnslie  cnli-ii  lerat  inn-.  \\\\\\  rcirard  tn  the  t're(|llcney 
111' a  ISital  tmiiinatinn  in  n-ciieral.  definite  <tati-tics  are  tint  rc.idily  altairi- 
alile.  .MthniiLdi  a  ninrtality  nf  fnun  n  In  d  ^f'^  cent.,  mi  the  nne  hand, 
and  n\'  .'50  or  oven  40  per  cent.,  nti  the  other  hand,  i-  mentiniicd,  it  may 


/••.in/,  77.7.' u/ V.I 770 .V.     fnctiyo.srs. 


388 


!»'  >lat(il  ;it  tlic  (iiil-rt  tli:it  >ii(li  cxlniiic-  arr  alliihiilaMc  tu  (|iiil«' 
ilctliiilc  (•(iiiililinii-.  LraviiiLT  lln-c  jxruiips  citCa-c-  mit  ot  (•(iti>ii|(i-:iii(iii, 
till'  irciicral    niintality   i^   .^tatol    liy    the   earlier  ela>-ieal    wi'iiei-   i<p   lie 

lieI\\eeM  |S  ;iTlil  'JD  JHTeelll.  .\c-ei  >niil\ir  tu  inuiliril  e\  Jx  rieliei  ,  \\k\v- 
ever,  il  i-  ili-tiiietly  lower,  namely,  iVoiu  '.•  to  1  _'  |iei-  cent.,  ami  at  iiiu-i, 
1  I  |iei- ei'iit.  IiHiniiy  as  to  tlii'  eaii-es  llir  tl.i~  reiliielioii  in  luortalilv 
will  -lidw  that  il  i- due  in  part  to  inqiroveinenl  in  -|H(ial  inelli(Hl>  ol' 
Ire.ilnieiit  and  in  the  ireiieral  liyLiienie  eonilitioii-,  and  jio—iMv  al.~o  to 
a  rednetion  in  the  virnlenee  ot'  the  di-ea-e,  in  tavor  ot'  which  i-  the  e\  i- 
denee  which  i~  availah'e  with  rcLrard  to  the  liehavior  ot'  other  inl'eetioiis 
ili-i'a~i'  in  this  re-|iiet.  .V  more  ini|ioriant  intluenee,  howc'Ver,  than 
th<'-e  (actors  ill  reihieini.'  the  j  e-ent  mortality  re~ide-  in  the  pert'cctiou 
of  dia^rni'-i-^,  so  that  a  l.irij-e  ntnnlier  of  ca-c-^  |ir(  \ion~lv  not  con-idered 
a~  typhoid  fever,  which  unexceptionallv  tei-iiiinale  in  recoverv,  are  now 
rocotrni/ed  as  e\ampli'~  of  thi-  <li-ease.  Thi-  ciicMin-tanii'  i~  taken 
account  of  al-o  hy  a  niimlier  ot'  earlier  writers,  who,  in  e-limalini,'-  the 
niortalil\,  excluded    the    mild   cases   at    the  ont-et. 

Tims.  ( iriessiiiL'-cr  deduets  from  oK)  c;i.se.-.  n|'  t\|ihoiii  t'ever  10  of  mild, 
fehriciilar  character,  and  eslimalo  the  iiiorlaliiy  ot'  the  remaiiiinu'  470  at 
l'^.*'*  percent.  Murchison  arrives  a;  approximately  the  >ame  tii^ures.  lie 
found  amiJiiLr  -'•"lO'J  cases  in  the  Lomloii  Fever  Hospital  fur  the  \cars  l.s.4.s_ 
]^>')'2  a  inorlality  of  \K.')  per  cent.  Thai  his  and  Ciries>iiiL''er's  results  were 
the  expression  of  liic  ireneral  inortalilv-rate  in  tvplioid  fever  at  that  time  is 
indicated  liv  the  result  of  an  inv>>liLration  of  jS.tirj  culleclcd  ca.ses  i  from 
London,  (dasL'ow.  Paris,  .'^trasshur.',  and  the  I'"rencli  provinces  1  of  the  tit'tli, 
sixth,  and  the  lieLdiuiinir  of  the  seventh  di'caile  of  the  nineteenth  centurv, 
whiidi  likewise  yielded  a  mortalily-rate  of  I'^.oL'  percent.  The  conditions 
at  Vienna  wen'  remarkaiilv  more  unt'avondile  during''  the  same  perio<i.  In 
the  Vienna  (ierieral  lIos|iital  there  were  ohscrved  helween  lS4()and  l^til 
■Jl.l'Slt  casis  of  ty|ilioid  t'ever  with  47()'<  ileallis — L'-.'.J  per  cent. 

These  liirurcs  may  he  compiired  with  some  ot'  more  re<'ent  date  ;  there 
were  treated  in  the  .lakolisspital  ot'  Leipsic,  from  l^sii  1,,  |,h;i;;,  1()2<;  cases 
of  typhoid  fever,  of  which  24-';  — ll'.T  per  cem. — lerminaie.l  fatally.  Ijirlier 
statistics  hy  I'hle  from  the  same  hospital  showed  that  tliMl  patient.s  exhihiteil 
the  averaire  mortality  ill  that  time  of  IS.,")  p,.r  cent.  In  the  epidemic  ef 
is.mi-lssj  at  llamhuri:,'  the  iiKU'tality-rate  was  comjiaratively  favorahle. 
Of  ll».Xli.'!  patients  throuj-hout  the  entire  city.  .H4(l  died — X.')  per  cent, 
■fliey  were  distrihutod  throicj-liout  the  two  vears  as  follows  :  IXSi;.  '.W4X  ca.ses. 
with  :i)i4  dea*hs— !J.2  per  cent.  ;  1S,S7,  ()S7.")  cases,  with  47f«  ih'ath> — l!.!'  per 
Cent. 

Of  the  ;!(!S(1  patients  of  this  LToup  treated  in  the  hos]iital,  the  niortalilv 
was  somewhat  hi^'hcr — :'.t)L*  !>.S  percent.) — undotilitedly  on  account  of  the 
smaller  nuniher  of  mild  ca.<es.  As  comiiMri>d  with  tln'se,  the  statistics  of 
Thiintrel  are  int.'rcstinir.  whoiiliserved  amon^r  ,'>(I4  patients  in  the  same  hosi)ital. 
het  ween  the  years  IS.lSand  iMil.  iHi  deaths  —  lit  percent.  Finallv,  1  woiiM 
state  t'urlher  that  a  study  of  oCOd  cases  that  I  treated  pcrsonallv  duriiiir  the 


.1 


:5«t 


rvriioin  i  ivin. 


t 


l„ii...l    ir-ii,    1-77    \'>    !-''7    i!i    \\\v\"\i-    |>!:i'-r^      I'.rHii!.  HiinilnirL:,   I..l|isic) 
cxIiiMl'il   ;i   i"ial    iiini-i:ilil\  III'  '.!.:;   |iir   ithi. 

Kuril, ^  ill.-  Ml  \r;ir-.'  I>>;i  In  l^'.''-'.  nl  >-J'.l  ril.-.-  I  n  illnl  111  liir  .li.lilis 
lli.|.Liii-   lli.-|.llal.  li  ;  iliiil      :i  iiiiiil;ilil>-|-aU-  uf  ~.  >  |ici   r,  i,|. 

Ii  |i:i-  Im-.ii  |i<iiiiliil  mil  llial  liic  ll-iin-  L:i\<ii  'an  !»■  apiilicalili  ■mly 
ill  a  -iiirral  ua\.  'Iln^  \arv  innlir  iliMi-r  iipinlili.iii-,  paillN  imli- 
vi,lii:il,    luilU     "iiiiral,    iml  ilinclls    ivlaliii-    In    llic    paliiiil.       It   i-  wrll 

kiinwii  iliat   ilii'  iialii\   \,iiir-  \\'u\i\\    iliiiiii-  ilitliiviii   epidemics 

ami  eudeuiies,  .jn-l  a-  llir  riiaiaihi-  ami  llic  |-iviiliai  ilii-  c,f  llic  (li-ca-i! 
liia\    lAliiliil   -nat  xarialimi-  in  .lilail  al  cJitV,  i ciil   lime-. 

Tlic  rxinil  I.I  uliiih  climate  ami  season  arc  .,|Mralivr  in  llii- cm- 
iici'li.iii  a|i|Mar--  m  li.'  mil  m  1  -iillii  i.iil  ly  ilil.rn.in.  .1,  allli.iiii;li  Mmvlii-.m 
liilirvci  llial   iVmn  a  -imly  nf  lli.'  -lali-li.-  "I'  ili''  I/imii'ii   !'.  a.  r  Ii.i-|ii- 

lal    li.'  ua- alil.'  til  iiiakr  nut  a  Liival.i'    i lalilv    iVnin    lyiilmiil    tiv.r   ill 

ill.'  -iiiiii.'.  Gcog;raphic  ami  racial  differences  aiv  in-inniti.ant 
in  lli.ir  inlliirm-.'  iiih'II  lln'  nn'iialily.  A-  i\|ili.ii.l  I'.m  i'  i~  di-l  rilmlol 
nv.ralim.-t  all  |iarl-  .'I' tli.'  wul'l  ami  ...null  i.-,  -n  it-  \  iinlcmv  a|i|H;irs 
t.i  lir  .•v.Tvwh.rr  aii|i|-ii\iinal.ly  ill.'  -am.'.  Wlniv  .li-lim-t  ililli  r.liccs 
willi    rt"_^;inl   In   iIh'  imnialilw  paiti.iilaiiy  in    an    iiiilaN .  .ralil.' liiriTlimi, 

lire   apiiari'iit.    lln-r   ili|"nil    i-|i.iially    ii|i.mi    '• Iiinalinii-    willi    ..llin- 

.-.•v.rr  iii.iilii.l  -lali-  nf  li'.al  .iii-iii.  An  illii-l  iMlimi  nl'  llii-  i-  all'mil.  .1 
liv  malarial    n'-imi-.       in.'.ini|iaral.l\    l..il.r   kiinwii  ami  imnv   ini|i.irlant 

than  tlic-i'   iicm-i-al    lii.'iiT-  1-  iIh'    inlliicii.'i' of  |i.i-..nal   i.lilinii-   ii|"iii 

till'    imirlalilv.       ll    a|i|Mar-    lV..iii    |iivvi.>ii'    -taliimnl-    llial   age   i-   nl 
irreal.-i    iiii|inrtamn    in    thi-    .nmi.-.'i  i.m.      'i'lm   ilanu't'i-    tVnm  tlic  <ii-ca>t' 
imava-i-  ra|ii.ll.    w  ill  ailvaniiiiu'  year-.      A-  rai'ly  a- al'liT   tlir    liirlictli, 
ami    |iarlinnlarl\   all.  r  tlic  lifliilh,  yrar  llir    malit;iiam-y  nf  tlic   .•niii>r  i> 
LH-cal.  wliiln   it  i-  iiml.iiialily  l.-a>l    in   i-liiMi'.'n    li.tw.vn    tlic   -(rnml   ami 

the  tciilh    v.ar.       In  ih.'  lal.  r  year-  ..I'ch.il.ll <1,  ami    in  the  .-nl>-i'(|iieiit 

;,^r,.-i,|.ri.i(l-  in  a. hill-,  np  In  ih.'  nii.l.llc  nf  ih.'  rmnMh  .le.-a.le,  the  .litVcr- 
,,,!,■(-  in  ihe  mnrialiiv  ami  the  rajiiility  nf  ii-  in.Tca-c  willi  a.lvaminu' 
v.ar-  aiv  I.—  -iii-niiieant.  Imt.  "ii  -imly  nf  a  lame  imiiilier  nf  ea-e-,  ih.y 
aiv.  nev.  rth.  1.-- ,<li-linetl\  a|i|ii-eeialil.'.  Thii-,  fnrtlie  jicrind- iVniii  tw.nly- 
llvi'  In  ihirlv  vear-  ami  fmm  thirty  tn  fnrts.  tli.>  |.rni:iin-i-  i-  .li-liii.'tly 
n,.iri'  nnfa\nra!'lc  than  in  the  |Mvin,l  tVnin  Iw.lve  m  twenty-live  year-. 

Til.'  li-iirt>  ef  nie>l  vril.rs  a-rce  willi  llin>e  ijixcii  in  the  lahl.'  jm 
y.  :;>:..  'I'lm-.  I.ieh.-rni.i.-l.r.  animi-  174:',  i-aM'S,  .liirinv'  IMi.'i  In  1>7(I, 
f,.ini.l  a  m..rtaliiv.ir:;tl  |,.T.vi,i.  tnr  lli.' aL'.-|ierin.l- ah.ivc  fnrty  vcars  ;  while 
in  th.is.-  Ii.l.i'.v  il  wa.-..nlv  !  l.>  per  .vnl.  I'liK'.  al  I  li.' diiii.' ..f  Wiimlerlieli, 
(.Us.rv.Mi  -i.alli  iH-.-iir  in  iiimv  tii.iii  half  nf  llie  cases  in  pati.nls  ah'.ve  llie 
U'j.-nf  fnrlv  years.      <  !ri.s>ii:L'.r  ulili/es  these  la. Ms  tnr  an  iiileri'sliir.' explaiiu- 


ws.- 


tt- ' 


FATM.  1 1  i:\ii\Ai  iii\     rj:i)i;.\nsis. 


386 


tinn  of  I'crfain  xlrikiiii'  ilitrinncis  in  tlu-  nmrtiililv  in  ilitl'tTcnt  h<>ci>iln!«. 
\\  liilc  lie  Id^i  1'^.."<  |itT  riiit.  1)1'  lii.'^  piitivnls  ill  /iiricli,  iiiiiiiiiL.'  hIkmii  iIkpsc  in 
llic  ii^'c  |»'rii>«l  iilicivi'  tiirly  vcmis  iiiiiiiiifnil  I2.li  [kt  ctnt.,  Kicdl.r.  in  I  )r<i<- 
ilfii.  with  iiiily  .1.1  |..  r  i-.iii.  (if  ilif  hillir.  Iiml  ii  iiKirliiiily  (if  (uilv  i:!.!  |nt 
(•(■lit.      Tlic   tniciiiir      I'l;.'.    17.   ir^    (siu'ciiillv   iii:-lriiitive,   in   whicli    Ficdlir ' 


tjt 

1 ..., 

..-■ 

,. . 

jf 

•'  ■ 

„- 

ill 

.-.„ 

:... 

... 

■*  •  1 

/ 

/ 

/ 

' 

i 

/ 

/ 

•  ) ' 

/ 

/ 

/^ 

y 

^ 

/^ 

-> 

i  I'Jl 

) 

V 

/ 

y- 

^^^ 

- 

— 

a* 

/, 

r 

— 

. — 

-  - 

-- 

— 

-A 

prosonts  tlip  ]«TceiitaL'('-rflMliiiii  of  tlic  ilcatli.s  frmn  ty|ilii>i(|  fever  to  the  total 
imiiilier  of  ra.-<es  of  typlidid  fever,  and  tlieir  relation  to  ai.'e-|ierio(ls.  I'roiii  tlie 
material  of  tlie  llre.xdeii  (  ity  ll(is|iital  diiriiii:  tliirty-foiir  year^  i  iX.'iO-lMS^). 
Tlie  relation  of  aire  to  the  mortality  i.s  exhiliiled  hv  the  fi.ilowinjf  table 
prepared  from  the  llainlMirj,'  statistics  for  the  vears  iH«t)-lH«7: 


1  t. 

Ii  l. 

-'l   V 

10' 

t 
•ars 

11 1. 
l.-l  t. 

14 

L'll 

.■',1  t. 

:!0 
10 

41  to 

1;-) 

4i;  t. 

M    t. 

•V) 

.'it;  ti 

(ill 

\ 

ini 

icr  .if  ca 

M) 

1  .V, 

IKHI 

(Ul-J 

i-j; 

HI 

L'Ci 

13 

8 

Dfatlis. 

IVrccntiige. 

2 

4.0 

10 

•-1.4 

•ii\ 

8.2 

w. 

8.7 

77 

1       ( 

74 

1-J..'! 

.11 

ll,.-> 

111 

14  !• 

1.-. 

is..-, 

.S 

L':l.O 

3 

:!7,.'i 

Till'  (liftoreiiois   in    projrnnsis  (lejx'niiciit   ii|«)ii    sex  are.   in   contf;!- 
(ii.stint'tion  to  tiio.^o  duo  to  ajre,  very  .-li^dit.      Tiie  little  dirtorciiec  that  i.s 

'  S.-parnlnlxIrurk   aiis   tint    lirrii-ht,-,i    ,1,-r   (l.-yrlhrhaft    f.    Sutur-  iin,l  ll,-il kiitnlr  zii, 
Drrs,lr„.  1884.       Thi^  valuiiMi'  ]iuMic'!iti..i!.  u  liiih  c.ntain.^  a  lari;i.  amount  of  carefully 
stuiiicU  statistical  data,  is  much  tuo  little  knuwii. 
26 


•■>. 


I 


3gf  rvrii'iih  II  VII!. 

iip|.:nviit  ill  llii-  rniiin'.'li..ii  i-  line  ni  iiiiii  niliirr  i..  .At.  iiimI  .\\\<\  -"lal 
.■ciii.litinii-  ("<-<iil>:ili"ll.  in...l.'  ..I'  lili',  Ml.-i.li..li-iii)  ;  wliil.'  in  U'lii.ii  ill.' 
-.MM I  rim.li..ii-  aiv  .In.  .  tlv  ..I'  iiilliuti.-.'.  |.Mrli.  iiImiIv  ihv^'Iimih-.v.  |.iirtii- 
lili,„i,  ,111.1  ill.'  |.il.|-|i.  riili.i.  If  :in  .-|...i:ill\  i:ir'_"'  iiiiliil..r  i.f  M  ..liirll 
:iiv    :i.-.i.|.iil;ilU     r.v.i\..l     inl"   -i    li.-|>il:>l     in    .-.iii-.  ( iii.ii.c   ..I'    cM.niMl 

,. |iii.,n-.    ill.-.'    I:i.|..r-    in;i\     I"     "t'   .  ..iih.IcimI.!.'    iiilln.'li.  .'     hih.ii     llif 

iii..rt:ililv  if   ill.'  |.:iri.nt-  ;ii.'  I;ii'-.  1>  nl   lli.    |M'i'i."l  i.f  ;i.l..l.-i'.'ii.'«'.     1    li'ltr 

,,r,|iiKir\     .HI' -laii.'.-    lli.'    .lilV.i.'H.'.-    ni     iM..l'l;ilil  \     ImI«..ii    iIi.'    Iw.i 

-.■\.-  111'.'  -..  -liLilii  iImI  iIi''.\  ''111  '"  :ilni.i-l  ciiliivlv  ii;n..nKl.  Ii  i- 
l,i-|,l\   .'li.ini.  1.  ri-ti.'  in   I  lii-  .  ..iili.  ■  l  imi   lli:il,ili   llii'  .'..ill'-.'  ..f  :ill  .'pi.l.  irii.' 

..f  l\  plii.i.l  li'N.i'  ..I' ...ii-i.l.  I'liM.' ilnr;ili..ii.  ill.    i,i..rl:ilil\  ; iitr  iiiiii  inav 

;ll    tiiii.-  .'X. '.'..!   llnl   :iin..liv    win.'n.  :ili.l   '■'.'.    i.rs,!.      'riiil-,  :il    I  I.'iliiliiiri: 

ih  ill.'    \.':ir   IssC,   ill.'    I lalilv  :ilii..ii':  iiicii  ("^.■".    |m'|'  .'.ill. )   u  a-  tr>'':i'"'' 

lliaii  am. Ill-  \v..ni.n  (:'..'">  j..  i'  ..nl .  I  ;    wliil"'  in  'li''  y>'^''  1'"*"^"  '''■''  aini>n^r 

«.. ill. 11  I 't.  I  l"'!'  .'.III. )  -liii'ii  I V  '^''' ■'■'''■''  '''•''  ■""""-  ""■"  '■'^■■'^  I"''  '■'•"'•I- 
It  i-  11. It  W'iilli  uliil.'  I.I  |iri-.nt  luri'  many  -la  l.'lii.'iil-  ..f  ulliui'  wi'ilir-. 
With  a  li'W  .■\.'.'|.li..ii-  llii'X  nai'li  liki'  r.'-nli-.  Alm.-I  rNa.'lly  liio 
sun.'  m.irlalilv  i-  -li..\Mi,  lin'  in-lan..'.  in  lli.'  f.lli.wiii'.'  laliU'  li>  Miir- 
I'lii-.pii,  in.'ln.rniL^  i^^'Ji'  .'a-i--  ..f  l\  |ili  li'i  fi'vrr  Inalril  in  llif  LiiihIiim 
F.'V.'i-    lli.-|iital    liclwi'i'ii    ill.'   >i'ar~    l^l>^    ami    IS.'iT; 

Aaini>>l'ilis,  I(.'nths,  1'.  ri  .  hti.i;o. 

Mill.'-      '■'"■'  "•"  '■'''' 

F.' 1.-  '""■  ""■'  '-'■'' 

T...:,l  l"*^"  •'•■••  '"-■' 

Tlii-  lalil.'  nia\  l.r  t'l.ll.iw.il  liy  ..ii.'..f  U.'.'l/,  trmn  iIh'  Mnni.li  in.ili- 
<-al  .'liiii.',  in.'lnilin-  lli.- .'a-i'-  ..f  ly|ili..iil  ti'Vi'  liilwi'.n  tlii'  \.'ai->  |S7  1 
an. I  l'-<7T.  ami  I'xliiiiiliiii:  a  niarkiil  i.I'.'Im.ii.Iitiii.'.' ..f  llic  im-rtality  in 
IIIIII.  rnilial.h  \M'  has.'  ii.iv  an  inii-li-ali.in  .if  llic  intliU'm'i'  of  .•iTtaiii 
iiijiiriuus  li:iliil>  i.f  lil.'  in  nn'ii  (alnilmlii'  "M'r:-^.  iiarli.iilarly   "f  Im'.t). 

MMrtMlily-l',  rc.iitiii;.' 

^"■^"•"-  liiinr     ..-..niuiT;^     t:,„t 

1S74 ^^        ^■'  '■" 

1K7-  !-■  ""■'  '"'■ 

,^--  l:),(i  7..".  '.I.'.) 

AK-i,  ilii'  social  position  am!  tlic  occupation  ar.'  not  of  so  nin.li 
siL'iiili.-in.'.'  Willi  iviiiii-il  t.i  the  |ir.i..'ii.i<i--  in  typli-.i.l  f.-v-ra-  with  rc-anl 
t.i  iliat  ill  iitliir  infcrtiiiii^  ili-fM-.'s  a-.  I'm-  iii>t:iiii'c,  lypliu-  fi'vcr.  I 
licli.'v.'tliai  tvplioiil  f.'V.r  lia<  a-  liiil.'  I'l'ialinn  l.i  w.-altli  ami  |i..v.rly  a-< 
til  ^'jvvial  .H'ciipaiii.n-.  It  is  not  cviii  apiiannt  tliat  an  imliir-nt  inmlc 
of  life  is,  in   itself,  injiirioiis.      On  the  roiitfarv,  tin'  mixle  of  lifo  of  llu 


F.\  TM.    77 7M//.V.I  /7o.V       /7.'o/,.\ os/\ 


387 


lii'h  is  iilinust   riion'  rrr(j!iiiii!v 
lion-  |iri'<li-[Mi-iii'_'  I'ai'tdr,      \\ 


U>  Ih 


l;ik. 


>ii-i<l<T:itii>ri  ns  an  i 


•un- 


til IN  |ili(>i>i    t'i'\('i'   ii 


■tliir  tlic  irtc'iipaiii.ii-  iImi  liivor  iiilii-tion 
I'l'  IliiiiliKrv)  an'  to  U) 


mwliat  j.'ri  itiT  ili'i.'n 


ciiii-iJiiid    iiMii-c    iiiilavunil 


il..,   I 


runi    tl 


jiP'^'i 


-I.IIM 


r\rii'i|lll''l\     iloll 


litl'lll. 


In  riTtain  -ii|M'rli(i:il  r(-|ic<t-  tin 


11   U 


A-    I  -     It 


I. 


W  llMt    rilnri'    l;l\  1 


-iliialnl 


true.  ;i|i|irar 
riitv  arc,  in   i^ciicitil    alilc  Id 


CIllllC    IIIKl) 


-c'i'iirc  niori'  cant'iil  niii-iiijr  ami  attrinianrc,  and,  almvc 

irraliiiciit  early.      Tiic  ic-iiltini:  aiivanta^c-  in  llic  pliv-ician  in  iiis  dailv 

I'Mitiiii-  arc  in   my  c\[Mricncc  aUo  a|i|)rc(ialiic  in  the  lio-pital,  since  jicre 


Ilic   |>^lnrI|l,i|^  II 


fill. 


iiiiirU 


arc  pTcivcii  c\ccc< 
llic  i>a-c<  adinittcd  at 
rtcd 


wliiili,  l)y  rca-dii  (if  iint'avoraMc  circiini-tancc- 
laic,  i-i    ^cncndiv  far  more   L'i'a\c  than   that   "'■' 


an  carlv  -lairc 


A  nut    incun-idcralile  iiitliicii' 


cxcrlcd  ii|Hin  the  pn.urnnsi-  hy  the  constitution  and  the  condition  of 
general   health    pre-ent    iicf..rc   tlie  attack  <<i'  typhuid   t'cvcr.      With 

ill  y<nin>.', 
lias 


ri'L'ard  to  the  eon-titntion,  the  daiiin  r   i-    t'rotii  the  nnl-i't  lea-t 


niii-ciilar.  -pare   iicrsoii-,  the  -o- 


illiil  toiit.'h  individuals  ;   whih 


•II  iiictitiiiiiiHi,  ill- 


pro^' 


rnosis  mil 


-t    I.. 


made  with    irreal  caiilioii   in  the 


it'  olic-e  pcr-(Plls,  e\cl|    yolllli^  iillCS,   lilcli 
d  ehl" 


as  \\(  linen. 


Ill  adilition,  anemic  anil  clilorotic   pei-ons  are  expo 


11 
-cd   t. 


■at  d: 


'i'hat, 


Hirer  ; 


tliat    in  alcohiilii'-. 


1" 


in  other  oircction 


s,  th, 


ddirted  to  n 
itlook 


rp 


ihl 


tllo-e    n 

1 


IS  lintavoraiilc,  need  xuireelv 


eiiuihasizci 


Amonir  the  evecssc- 


)liv>ica 


1  and 


mental  overexertion  arc 


rt'iel'. 


to  lie  included,  as  well    as   j)rot'oiind   eniutional    di-ttirliaiices,  irreat 
Anioiiir    chronic    diseases,     irimt,    diahetes,    heart 

orLims,  p.irticniarly 


mil    anxietv. 


<iisea-c,  IK 


phritis,  chronic  disca-c  of  tli(>  respiratorv 


advanced  tphorculosLs,  arc  to  he  considered  as  cspeciallv  iiiifav(;rahK'. 


TIME  OF  DEATH. 

The  early  or  late  occurrence  of  death  depends  in  the  individual  ca-o 
e-peeially  upon  the  aire  and  the  constitution  of  the  ]>atieiit,  upon  the 
-[iccial  form  of  the  disease,  upon  the  distriiiutioii  of  the  tvpiioid  process 
in  the  various  orj^ans,  as  well  as  upon  the  niimher  and  the  character  of 
the  com|ilications.  l?eference  will  he  made  later  to  a  niimlicr  of  espe- 
cially inijiortant  ]Kiints  in  tlii-  connection.  It  is,  however,  not  without 
value  to  oiitain  ireiiei-.il  fij.rures  with  rejrard  to  the  time  of  the  fatal  ter- 
mination. The  larL'est  iiumher  of  deaths  in  aveniire  epidemics  of  ordi- 
iiaty  character  occurs  hetween  the  <(fin\<\  half  of  the  s<H.nnd  and  the  enil 
"f  the  fourth  week.  Death  is  much  less  common  at  an  earlier  |ieriod. 
It  occurs  even  with  distinctly  trreater  fre<|iiency  after  the  thirtieth  than 
before  the  tenth  day.     It  is  uoteworthv  and  in  accurdauee   with   the 


Mdi 


M 


'i 


m4 


;i8s 


TYflldlD    I  EVin. 


rclMtivc  linxitv  of  tlic  comx'  of  tlu'  di^ia.-f  in  chiliinii  tliat  tlif  lar^ot 
limnlicr  .il'  dfalli.-  in  tlicii'  orcurs  lictwccn  tlir  Iciilii  and  tlif  twciily- 
(ir-I  <'a\-.  'J'iif  >|H'(ial  cliaractcr  ot'  .-oiiic  ciiidciiilr-  i-  nianiti>lt<l  liy,  in 
addilion  t<i  otlit  r  ffauiro.  a  rt'inari<aliiy  early  |HTioil  for  liic  occnrrcnct> 
(ifdiaili.  TIk'^c  ('|iid( mil-- arc  cliai'actcrizi'd  iiy  ilic  frciincnl  occurrcnci' 
of  j)rofonnd  intoxication  or  (-intiaily  early  inio.-tlnal  hen.orrliatre.  It  is 
of  jii-aetical  iinj>oitanee  to  note  tliat  death  may  occur,  and  liy  no  means 
rarelv,  Ion;:  after  tlic  termination  of  the  fcWrile  sla^'^e.  Marasmii-. 
Hlui:c;i>li  j)roce->es,  anil  >e(|nels  play  an  iinpoilant  rnh-  in  tins  coimeetion. 
I  have  ol)serve<l  deatii  occur  as  late  a-  the  one  hundrnl  anil  twentict'i 

day. 

(  )ur  Leijisic  tallies  siiow  a  fatal  tcrminatidii  in  the  eleventh  week  in  4 
cases,  and  tlie  Han,  iutl' statistii's  sli'nv  "Jti  cases — 7.7  jier  cent. — in  which 
death  (lecurred  after  the  hflieth  day.      IJoth   tallies  are   herewith  appended. 

JUath  occurred  at  jA'i|>sic  in  the  first  week  of  the  disease  i"  t)  cases — 
2.5  per  cent.:  second  weik,  o7  cases — !•">.  1  jM-r  cent.  ;  third  we.k.  ti.'i  cases 
— 2r>.'J  per  cent.  ;  fourth  week,  .'>!  ca.~e.s— L'n.!)  per  (-iit.  ,  iifth  week.  l."2 
cases — 9  per  cent.  ;  sixth  week.  20  c:i.-ies^8.27  j)er  cent.  ;  seventh  week,  i* 
cases — 3.7  \>eT  cent.  ;  eifrhth  week.  7  casi  s — 2.1'  per  cent.  ;  ninth  week.  5 
cases — 2.1  per  cent.  ;  tenth  week.  2  cases — 0.^*2  f>er  cent.  ;  eleventh  week, 
4  cases — 1.0  per  cent. 

Death  thus  occurred  between  the  second  and  the  fourth  week  'n  151 
eases — <i2. 1    per  cent. 

At  HiunhurfT,  among  ;;()2  cases  of  typhoid  fever,  death  occurred  between 
the  sixth  and  the  tenth  day  in  11  ca.ses — :>  per  cent.;  eleventh  and  the 
fifteenth  dav  in  •')!  cases — 14.1  per  cent.  :  sixteenth  and  tlie  twentieth  <lay 
ill  ('.<H  cases— IH  percent.  :  twenty-tirst  and  the  'wenty-tifth  day  in  4t>  eases — 
12.4  jier  cent.;  twenty-sixth  and  the  thirtieth  day  in  45  cases^l2.4  per 
cent.;  thirtv-lirst  and  the  fortieth  day  in  ;>5  esises — 11.4  per  cent.;  fortv- 
fir.st  and  the  fiftieth  day  in  21  ca.«es; — 5.8  jier  cent.  ;  after  the  fiftieth  day  in 
o^  ,..,a,,_s — 7,7  per  cent.  From  this  it  follows  that  in  more  than  lialf  of  the 
eases — I.  c.  21')  (58  percent.) — tleath  occurred  between  the  eleventh  and 
the  thirtieth  clay. 

.\ecordiii<r  to  most  observers  and  niy  owi>  experience,  the  pr(>jrno~is 
of  relapses  is  in  ^reneral  more  liivoraMc  than  tliat  of  pritnary  attacks 
and  of  nHTiidescences.  Of  the  cases  of  tyjihoid  fever  with  relai).se  at 
Ilandiurp,  I   ohserve<l   deatli   in   4.!>    per  <  ent. 

CAUSE  OF  DEATH. 
The  causes  of  death  in  detail  have  ])r"viously  been  .somewhat  di.scussed 
(sec  the  chapters  on  SvmptomatoloL'V  and  on  Course  and  Termination). 
With  resrard  to  manv  ])oints,  therefore,  reference  must  be  made  to  them. 
Death  results,  on  the  whole,  in  one  of  thn-e  ways.  In  the  first  i>lace, 
in  consequence  of  the  severity  or  the  sjMH'ial  character  of  the  intoxi<'.i- 
tion  ;  m^xt,  in  coniie<'tioi  with  unii>nal  dev(>loi>ment  and  -evere  course 
of  the   peculiar  localizations  of  the  disease,  especially  in   the  inte-tinf, 


::m^Mi£2m:'^M^- 


r.WM.  ti:i:m/\.\tio.\.     i-iKxtsusrs. 


;{89 


fill'  rcspinitdry  orjr-iii-,  lliu  iiL'rvi)ii>  >y.-tiin,  ami  tlio  kidncvs  ;  and  tinallv, 
ill  consocjiieiur  of  tlie  si-at  ami  the  sovcrity  nt'  the  actiial    coinplicatums. 

Tlio  severity  ot"  the  intoxication  is  prol)ai)ly  tiie  most  inijionaat  of 
the  causes  of  ileatii.  From  .'K'  to  oO  |)ei'  ceni  of  tlie  de^itlis  are,  in  my 
experience,  to  lie  attrihuted  to  it.  In  a  larjrer  sense  the  c;ises  that  jilirsne 
a  I'atal  termination  with  the  clinical  pietnie  of  the  hemorrhajxic  iliathesis 
ami  of  hyperpyrexia  may  also  be  incliide<l  in  this  catej^ory.  The  pro- 
found toxic  etliH'ts  are  exhiliitcd  espi'cialiy  and  most  conspicuously, 
an<l  often  simultaneously,  hy  the  central  nervous  system,  the  heart,  anil 
tlic  vessels.  Cases  that  ■ire  early  attended  with  profound  delirium  or 
deraiiLrenient  of  cl)llscious^e^s,  in  wliich  coma,  floccitation,  siilisultus 
tendiiium,  ciioreifortn  and  spasmodic  states  early  occur,  are  illustm- 
live  of  the  e-pecial  severity  of  the  toxic  action  niioii  the  central  ner- 
vous system.  Amouf^  such  manifestations  are  often  ineludwl  also 
rigidity  of  tiie  necU  and  the  hack  and  hyperesthesia.  It  may  he  noted, 
however,  that  these  features  may  he  early  and  markinl  also  in  cases  that 
siihseiiueutly  pursue  a  favcrahle  course.  On  the  other  hand,  they  may 
he  the  >yiii])toms  of  actual  complicating  meningitis. 

Although,  without  doiiht,  eonstitiition,  sex.  age,  and  individual  eir- 
ctiinstauces  occa>ion  a  variahle  su>ceptil)ility  on  the  |)art  of  the  central 
net  vims  system,  it  may  he  stated  in  general  that  the  prognosis  is  the 
more  unfavorahlc  the  more  profound  are  the  symptoms  referahle  to  the 
central  nervous  system,  and  the  earlier  tliev  a])i)ear. 

Liphe-nieister  niade  an  iiileresli.i;:  analysis  of  his  patients  in  the  epi- 
demic at  Hasle  lietween  jst;:)  and  Is(ix  with  reference  to  this  point,  and 
fouiiil  that  of  those  who  exhihited  no  striking:  cerehral  svni]iti)ins  during  the 
course  of  the  disease.  :>..')  per  cent,  died,  while  the  Miortality  in  those  patients 
in  whom  only  slight  conditions  of  e\-citeiiient.  of  short  duration,  or  occurring 
only  during  the  night,  had  existed,  was  l!t..S  p,.,-  cent.  Of  the  cases  with 
marked,  furious,  or  with  nuitteriiii:  deliriimi.  .")4  jter  cent,  terminated  fatallv, 
while  those  attended  with  so|)or  and  coma  exhihited  the  enormous  mortality 
of  70  per  cent. 

With  regard  to  the  ctl'ei'fs  of  the  toxins  upon  the  circulatori-  organs, 
the  disturhances  that  occur  in  these  are  also  undouhteillv  to  he  onn- 
sidcrcd  the  more  serious  the  earlier  they  occur  and  the  more  severe 
they  are.  They  are  usually  included  under  the  general  designation 
cir.liac  wcaknes-.  It  is  .ertaiii,  how(>ver,  that  in  eases  of  typhoid  fever 
and  (d  other  inftH'tious  diseases  disorders  of  the  v.isomotors,  as  has  heen 
pointed  out,  play  just  as  important  a  n'/r  as  disorders  in  the  activity  of 
the  myocardium  itself.  We  are  at  present,  it  is  tnio.  not  yet  in  a  posi- 
tion to  di-^tingui-h  definitely  one  from  the  other,  or  to  iMimate  the  share 
each  takes  in  their  apparently  freipient  corabinatioiis. 


'  !? 


.-^^•^i-'^--     >..Jti-     ,4s.    ---^„-<^fcs>- 


'  r?^  -^.-  •^r^lfi.^^g^^l^f^^^ 


rw  ^■i. 


Wtiil 


t'  ■  ''t 


a;io 


TYi'iKiih  ii.vi.n. 


Tlic  iui)>t  iiiijiciriaiil  -iiidr  to  llic  ^latc  ni'  tlic  circiilatiTy  orjrati-  is 
funii>lu>(l,  now  a-  alwav-,  liv  a  ^iiidy  of  tlic  |iiiIm'.  It.-  t'i('(|iifii(y 
alniio  mav  Ix'  nl' I'dii-iilci-alilc  iiii|pnrtaiicc — 1( — ,  it  i-  true,  in  tlic  ca-i^  of 
women,  cliil<li-<ii,  ami  other  nervous  inili\  iiliial-.  tliaii  in  that  of  rolm-t 
men  or  ehlerlv  per-on>  of  either  mx.  While  in  the  foinier  ^reat  fre- 
qileiiev  of  ]iiiU<'  a|i|iearinLr  early  is  eniiinion,  and  i-  of  ii-clt"  ot"  little 
siL'iiifieaiiee,  it  iiiii~t,  ill  >tidnLr  yotiiii;  men  oreldeily  iieivon-,  even  liy 
itM'lf  admonish  the  ilinieiaii  to  exerei-e  jrreat  caution  in  ])id!^iio-i-.  It 
liiav  even  he  a  matter  of  coiicer:!  if  in  an  a]i|iarcntly  ,-troii;^  man  the 
almost  typical  relative  .-lo\viie-<  of  the  |iiiUc  ^o  p^nerally  pre-ent  in 
the  first  half  of  the  i'ehrilc  >taire  remains  aliM'tit.  Dimimitioii  in  the 
tension  and  alteration  in  the  rei;iilarity  of  the  ))iilse  are  naturally  to  1)0 
eonsidere<l  still  more  serious  tl.aii  inereaM  1  fre(itiency,  and  in  this  eoii- 
neetioii,  as  has  Ix'cn  pointed  out,  more  importanee  is  to  he  attached  to 
irre}rnl:irity  in  t()ree  than  to  mere  irrcjfiilarity  in  rhythm.  As  a  matter 
of  eonrse,  the^e  di>tiirl(anees  are  all  the  more  sifijnificant  the  earlier  they 
appear,  the  Ioniser  they  last,  and  the  more  po.-itivcly  it  can  1k'  stated 
that  tliev  are  not  deiiendent  n|M)n  jirohalily  transitory  complieatioiis. 

The  cxtraordinarv  jn-ognostic  importance  of  the  state  of  the  eircnla- 
tion  was  especially  appreciated  by  earlier  ]>hy>ieians.  With  the  iiitro- 
dnetion  of  lliermoin"try.  and  the  jiriniary  enthusiasm  aroused  hy  this 
new  method,  it  was  undeservedly  jnished  somewhat  Mito  the  haekj^round. 
At  the  present  day  it  has  l)een  restored  to  its  jiroper  position,  and  there 
is  no  iloiiht  that  for  individual  ])r(>frn(>sis,  on  the  whole,  tlic  state  of 
the  ])iiKc  atfords  hetter  and  safer  <riiidaiiee  than  that  of  the  hody- 
tem]>cratnre. 

The  jirofinost'c  interpretation  of  the  course  of  the  tem|)cratiire  is  dis- 
tinetlv  more  ditricult,  and  i-  dc|)endeiit  ii|)oii  the  mo-t  varie<l  po»il)ilities 
and  the  most  comidex  conditions.  Although  formerly  ile<'i-ive  value 
was  attaclied  to  the  ah-^olute  heifrht  of  the  temperature,  without  ade- 
quate consideration  of  the  freneral  state,  this  is  at  tiie  |)reseiit  day  eou- 
ce<le<l  to  he  hut  limil"'d.  ami  a|>i»licalilc  only  to  rare  conditions.  Tempera- 
tures of  40"  r.  and  al>ove,  (-.pceially  in  adults,  if  fre(|Uently  rejicateil, 
or  if  a  per^i-tentlv  Iiigli  tem])c:  <ure-level  is  reached,  may  undoiilitedly 
l>e  considered  seiioii-.  The  pro<rno>is  is  under  some  circumstance-  reii- 
derfvl  unfavorahle  also  hy  ahnormally  low  temiK'ratiires.  The  collai)se 
anil  pseudocoUap^e  jireviou-ly  mentioue<l  should  he  iMirne  in  mind,  as 
well  as  tlie  persi-tently  low  tcinpe-atiirc-,  such  a-  occur  in  senile  or  in 
ju'cvioiislv  dehilitat.Hl  youthful  individuals,  and  which  heeome  iiwKt 
marked  in  that  dangerous  variety  of  typhoid  fever  that  pursues  an 
afebrile,  or  even  a  subfehrile,  course. 


t-i.--ri-^"'!r*itZir--'*--->-''t*t-  -■■ 


^    -  -  ^^^  '  i"     -      -'        ■  ■  -•■  ,  ''^l'>    •    ■.TV-* 


/•M  /'.I  /.     /■A7M//.V.t  770.V.       rilmiSDSIS. 


\vn 


Fiirtlicr,  pruiriKislic  coiiclii^ions  Iki-cnI  ii|miii  tin  iriii]icr!iture  >li(>iil(l 
iKit  he  I'liniuil  atUT  lno  >liMrt  a  |)cri()(i  uf  (il)~crvatinii  tw  witlidut  coii-id- 
,  itioii  of  tlio  reiiurmiiij;  (•iii'iiiii>taiici~.  liuliiil,  tlii'  rtatc  of  tlic  IkmH- 
tcii»i>i'ratiiro  in  ca^os  of  typlidul  fever,  as  in  xiinc  otlii-r  infections 
ili-eascs,  i>  as  nineli  ilcpciulent  upon  imlividnal  cireunistanee^  a-  i>  tlial 
of  llie  ncrvons  >_v-teni  and  tiie  circiilaiiTy  orj,'ans.  Ev.ry  pli_v>ieian, 
ami  e-peeiallv  tile  family  praelilioiu  r,  lias  ineontroverliMe  evideiici' 
of  the  fact  tliat  dillereiit  individual-  exhiliit  not  only  ilitferent  felirile 
reaetioiis  to  the  same  inflnenees,  hut  al>o  varying  degfees  nf  resi-tanee 
to  tiiosp  inrtueneos. 

Presnppo-ing  all  this,  it  i-,  nevertheless,  n-efnl,  e^jxrially  in  the 
first  part  of  the  diseasi>,  to  seek  prou'iiostie  guidance  from  the  state  of 
the  temperature.  The  licighl  and  the  character  of  tlie  curve  are,  in  this 
connection,  of  ccjual  imi)ortance.  As  Wnndorlich  and  his  jtiipils  have 
point(><l  out,  rapid  elevation  of  tiie  hodv-temperaturc  in  the  initial  stage, 
without  or  with  liut  a  suggestion  of  a  step-like  ascent,  and  a  high 
temperature  -peedily  rcaclu^l  and  maint;iined  tiir  a  consideralile  time 
without  material  morning  ren.is>ions,  arc  indicative  of  a  severe  course. 
Especiallv  the  hy|M'rpyrotic  and  fulminant  cases  ai-e  prone  to  l)egin 
with  a  rapid,  nninterniptcd  elevation  of  temperature  (Fig.  2o,  p.  2H!t). 
On  the  other  hand,  it  should  not  he  forgotten  that  es|)ecially  the  abor- 
tive cases  pursuing  an  unexpwtedly  rapiil  and  favorable  course  at  times 
set  in  in  an  almost  identical  manner. 

While  })ersistent  high  temperature  with  slight  remissions  is  in  gen- 
eral to  be  con>idei'eil  unfavorable,  evening  exacerbations  of  even  con- 
siderable height  p(-rmit  of  a  favoi-able  interpretation  if  they  are  associated 
with  marked  morning  remis>ious,  or  even  intermissions.  It  may  be 
stated  in  general  that  the  earlier,  tlie  more  marked,  and  the  longer  the 
remissions,  the  more  favorable  may  the  course  be  exjHH'te<l  to  l>e. 
Naturallv,  remissions  following  a  continued  fever  of  considerable  (hira- 
tion  inav  lie  welcomed  as  an  indication  of  the  early  advent  of  the  stage 
of  steej*  curves.  AH  these  circumstances,  however,  it  may  here  be 
repeatp<l,  become  more  valuable  from  tlic  prognostic  standjxiint,  the 
more  critically  the  conditi(Mi  of  tlie  Itodv  in  general,  and  especially  that 
of  the  pulse,  is  kept  in  view.  If  the  pulse  maintains  a  normal  course, 
danger  need  not  be  feared,  even  in  the  jiresence  of  an  ai)]>arently 
unfavorable  course  of  the  temperature.  In  the  ])resen('e,  however,  of  a 
snspieious  state  of  the  pnlsi',  no  cour>e  of  the  temperature,  not  even 
ap,.xr"ntlv  the  most  favorable,  is  to  be  trn-ted.  An  im|Hirtant  aid  in 
the  inter|uetation  of  the  pnlse  and  the  tcm]K'rature  may  Ix'  jirovidei! 
b_\  the  state  of  the  lungs.     Suspicious  changes  in  the  ibrmer  must   l)e 


Mil  =;:; 


,m  ■}i 


,.yi*: 


m 


p 


■M2  TV ri loin  ii.vi:n. 

(•iin.~i(i(n(i  tlio  more  serious  wlicii  cxlciisivi-  Ipmiicliill^  :i|i|)r;ii>  tailv  in 
jirfvidii-lv  iic;iltliv  imlividiial-,  ina.-iiiiicli  as  ii>  mvci'Iiv,  apart  tVoiii  its 
(l(]Hiul('iii't'  ii|Hiu  the  iiiltii-ity  nt'  tlio  toxic  rtrcct,  is  related  e-peeiaiiy 
to  tlie  iinj)airineut  of  earilia<'  aetivity.  Still  iiiok  (li-tiiietive  in  this 
comieetioii,  ami  .vnnetiiiie^  evident  even  lietiire  the  pnl-i'  ha-  ae(jnire<l  a 
(Icliiiiteiv  serious  eliaraetei-,  is  the  early  invoKcnient  liy  a  rapidly  jiro- 
j^ressivc  hroncliitis  of  pretiralily  the  ]io-ieiii>r  and  lower  jiarts  of  tlio 
luiifCs.  The  jifoirnosis  is  naturally  ino-t  imravoralile  with  the  onset 
of  actual  hvpostatic  conixer-tion,   .-iniple  or   iiitlaininatory. 

( )f  the  lo<'al  tvphoi<l  disorders  and  the  eotn]ilieatioiis  already  rc- 
j)eateillv  di>cU"ed,  only  the  nio-t  itnp^.rtant  will  he  coiisideied  in  this 
place,  and  then  e-peeially  in  ri^aril  to  their  |)roirno-tie  iin]iortanee.  ^\  o 
shall  con>ider  first  the  state  (.f  the  intotinal  canal.  The  oeciirrenie  if 
mcteorisni  is,  from  the  jiroirnosiii  point  of  view,  of  in"stiiiialilc  signili- 
aiiiee.  Aithoutrh  its  ap]>eurance  i-.  in  trenei-al,  little  to  ho  desired.  it3 
prcseiu'c  in  marked  dcLrree  and  it-  nip'd  development  at  the  heifxht 
of  the  disease  in  jiatients  the  ri'L''idation  ot"  whose  diet  has  not  Keen 
no<d(  ted  must  he  considered  as  actually  ominous.  'J"he  meteorism  is 
then  almost  the  direct  expre-- ion  of  the  deirree  of  toxi<- action  upon  the 
intestinal  nervous  svstein  ami  the  museiilar  layer.  It  should,  in  this 
connection,  \iv  expre— Iv  emphasized  that  the  intiii-ity  of  the  nicteorism 
is  liv  no  means  in  dirict  relation  to  the  >everity  of  the  diarrhea,  or  even  to 
the  severitv  and  the  extent  of  the  spei'itie  typhoid  le^ions  of  th(>  intes- 
tine. Thus,  r  have  ol)>erved  the  u-ual  meteorism  of  the  larLTO  intestine 
well  marked  in  the  ahsenee  of  the  sliirhtest  intilti-.ition  of  the  llillieles. 

That  the  fre(|Uency  ot'  the  sto<ils  is  no  index  of  the  detrree  and  the 
extent  of  the  medullary  swcUiiisr  ot'  Peyer's  jiatches  and  the  solitary 
f()llieles  has  heeii  ])reviously  emjihasi/ed.  Xcverthelcss.  eases  with 
severe  diarrhea  of  early  onset  and  loni:  duration  are  ini(loul)te<lly  to  lie 
considered,  in  LTcneral,  the  mori'  daiiLTerous. 

Of  irreat  importance  in  the  projrno^i>,  and  amontr  the  most  fro(pient 
causes  of  death,  are  two  other  manifestation-  on  the  jiart  ot'  the  intes- 
tines, viz.,  peritonitis  and  intestinal  liemorrhaLTc.  Peritonitis  is,  ot' 
the  two,  the  less  common  hut  liy  far  the  more  daiiL'crous  condition. 
In  the  nature  of  thing's,  it  is  in  the  overwhelmin<r  majority  of  ca.ses  not 
oircnmscrihed  hut  diffuse,  and  theret'ore  usually  fatal. 

Our  Leipsic  statistics  show  that  amonf:  the  fatal  cases  of  typhoid  fever 
death  was  due  t"  peritonitis  in  Hi.",  percent.  At  Hamhurfj.  whereof  til 
patients  with  peritonitis  .tI — >*:Mi  per  cent. — died,  the  proportion  of  these  to 
the  remuininc  fatal  cases  was  14  per  cent.,  and  if  all  cases  of  typhoid  fever  he 
taken  into  coiisi<leration.  it  was  found  that  1.4  [ler  cent,  of  then,  terminated 
fatally  from  this  arci<ient       Although,  as  has   l)een  nientioned,  the  severity 


FA'iM.   ri:i:Mi\.\'i'iii.\.     /7.'or;.\ o.s/.v. 


.•!!»:} 


of  the  tviilioid  iiitiolliial  lc?ii>iis  v:irie.<  in  ^ccDrthnce  with  teniponil  siii'l 
local  iiil'lueiK-es,  ibe  |ir(i|)<)rtioM  of  fatal  lases  Iroiii  pfritoiiiti.s  to  the  reiiiaiu- 
iiifr  fatal  cases  of  t_v|)lioicl  fev<T  will,   iicvenhelcss.  not  ii.-ually  fall  below  « 

j)cr  cent. 

Aiiionfj  llic  t;;!  fatal  ca.-ie.<  of  ty|iliolil  fever  at  tlir  .Iolui>  Hopkins  Hos- 
pital, 'JO  (ol.Tl  per  cent.  I  \\ere  a.-.-ociateil  with  perforation  ;nil  peritonitis. 
Therefire,  of  the  entire  ^21»  case.s,  L'.  U  per  cent,  terniinalml  fatally  from 
this  accident. 

Altlioii"-ii  a  iniicli  hirt^er  iiiiinher  of  cases  of  typlioid  fever  are  seized 

with  intestinal  hemorrhage  than  witli  jieriloniii.s — this  cniidition  i.s 

likeK  to  cM'ciir  in   from   .',  to  ■',  uinl  even  up  to  7  per  eeiit.  of  all  ca.-es 

— this     ircnnistance  i~,  iiowever,  ( ipcn^uted    tiir   l>y  the  fact  that  e\  eti 

in  the  severest   epideniics   not    more  than   from   20  to  ;5()  per  cent,  of 

such  cases  terminate  fatali\  ;  40  per  edit,  noiild   Im  tiie  e.\treii;e  limit 

Moreover,   it  sl„,uld  lie  enipha-i/.ed   that   at    timo  the  mortality   iVotu 

intestinal   iiemorrhatre   is  remarkahly  low,  and,  in  p'lieral,  i^  far  hclow 

20   jier  cent.     The  varialiility   of  the  condition-  in    thi-   coimeetioii   i> 

shown  hy  our  Hamhnrj^  ,stati-tie-  tWr  two  i-onscciitive  years  ot  vir'nally 

the  same   epidemic.      While   in    the  year    ISSlJ    20.!)    per  cent,  of  tlu! 

c^isc.-,  with  intestinal   iieinorrhasre  dieil,  ihi!  proportion  in  1SS7  was  oidy 

11. t)   per  cent.      In   >pite  of  the  nnieh  sli;,diter  daiiL-'er  I'nnn   intestinal 

hemorrhage  in  the  indivitlual  case,  its  mneh  i;reater  frecpieney  jtnts  it, 

nevertheU'ss,  in   the   front  rank  among  the  eatisos  of  death.      I  should 

estimate  its  mortality  at  about  two-thirds  of  that  of  peritonitis. 

.\nioisir  the  Sl'U  ca.ses  of  ivphoid  fever  at  the  .[ohns  Hopkins  Hospital, 
heiiiorrha;.'e  from  the  bowels  occnrred  in  'I't  ,  (i.O:;  per  I'ent  i.  Of  these  ."iO 
ca.s(s,  .')  I  10  jxT  cent.  >  died.  Or.  of  all  the  ca.ses  of  typhoid  fever,  O.ti  per 
cent,  terminated  fatally  from  this  complication. 

Scaroelv  le-s  dani;eroas  are  tlie  diseases  of  the  lungS,  espoeially 

the  various  f.>rms  of  pneumonia,  with  tlieir  se(|iiels — abscess,  jraii<rrene, 

etc.      In  severe  ejiidemics   from    10  to  ].")  jmt  cent,  of  all   deaths  can  bo 

attribitted   to   them.      I'y   rcas<i!>    of  the  i;n])erfect   development  of  the 

etioloi^rie,   and  espei'ially   the  bacterioIo!jri(%    basis  of  the  various   flu'ms 

of  pneumonia,  it  lias  hitherto  not    bet>n   possible  to  roach  definite  views 

with   rei^rd  to   the   |)roiriiostlc  siixiiificaiico   of  the   individual  varieties. 

In  i-cirarti  to  the  time  of  onset,  tlu'   forms  of  pneumonia   that  deveIo]i 

late  ai)|H'ar   to   Iw  especially  unfavorable,   liecaus-,  under  such  eircum- 

.stances,  livpostasis.  antere(lont  cNteiisivo  broiioliitis,  cardiac  enfeeblemcnt, 

and   vasomotor  di-lnrbaiicos  exert   an   unfavorable   influence  ;  but    al>o 

those  cases  that  develop  at  an  earlier  period.  ]  irticularly  the  initial  cases 

proirressjni:   under  the  picture  of  the  so-ealled  "  i)neunioiyphoid,"  may 

beeomo  (piite  daiiL'-erous.      That  a<ro  jilays  an  important  rrJr  in  tlie  |iroL''- 

iiosis  of  tvphoid  imeumonia  -cavcely  reijuires  special    mention.      ^\  hile 


III 


-■■p 


394 


TYriKiin  ii.VKii. 


ill  t\  pliiiid   piiticnts  ovir  lurty  "V  t^rty-tive   vcais  nf  a;:(>  tlic  cicciirniice 
of  [iiuiiiniiliia    i-    [Pidlialilv    aluay~   a    tlilal    cumiilicatiuii,    llic   iiKirlalily 

I'niiii   |iiu'iiiii'iiiia   in   rhildli 1   i-  low.      'I'lir   t'avoi'alilf  (•iiiiditioii  nf  ihc 

luarl  ul)viuu.-ly  iiK  r(a>L-'  the   puwcr.s  ol'  roi-itaiue  iiiuKt   tlic-o  circuin- 
slaiices. 

Pleurisy,  wliicli  i-  mucli  !«■--  (••iniiiiuii,  i-,  a|ian  t'niiii  llic  |)i-(-(nc(' 
of  i)iinili'Ut  anil  puliiil  cliur-ion-.  I>y  no  nuan-  -••  nntiivoralilc  a-  |inrii- 
iiionia  tVoni  the  jiroj^no,-.iic  staM(l|)oiMt.  Small  ami  even  coM-idcraMc 
ftl'ii.-ions  suli-idc  williont  initoward  <  nii-riiiicncc-,  rvcn  willioiit  llif 
nocositv  tor  jiiin  tiiif.  Thai  jialiint-  -iill'ninir  IVoni  ilironic  lirondiiiis, 
eiiijilivscina,  or  juiliiionary  iniicrculo-j-.  iictliro  tlio  <insft  ot'  the  typlioid 
I'l'VtT  aru  (  xpo-fd  to  nm^idi  ralilr  daiip'v  i>  a  matter  of  course.  Tlie 
relation  of  liiliereulo.-is  to  tiie  eciur-e  of  tlie  attack  of  typlioid  fever  lias 
been  fully  con>ideri'd  jinvioiisly. 

The  condition  of  tlie  kidney  is  also  of  j^reat  ini))ortance  from  the 
prognostic  standiMiint.  K\cn  the  cases  with  -iniple  febrile  aliiutiiimiria 
are  to  In'  con>idered  cantion~ly.  This  condition  is  indicative  at  least  of 
feelile  jxjwers  of  l•e^i^tanc^■  on  the  part  of  the  iMKly  to  tlie  action  of  the 
toxins,  and  it  is,  in  piiefal,  to  he  considered  the  gniver  the  earlier  it 
appears.  The  di-covery  of  tlie  excretion  of  alhnmin  may  he  of  especial 
si'Miifieance  in  j(i'ogiio>i>  if  it  iH'curs  at  a  time  when  the  temperature  is 
not  particularly  liigh,  and  when,  also,  the  pulse  exhibits  no  serious 
maiiift stations.  Nepliritis  has  a  notewoithy  inthience  ii|ioii  the  nior- 
talitv  althoujjli  it  is  not  so  iii)|«ii1ant  in  this  connection  as  tlie  diseases 
of  the  intestinis  and  the  liiiif::-.  Although  with  regard  to  the  fre<piency 
of  its  occurrence  it  occupies  a  position  tiir  beliiiul  the  latter,  it  c'ause.s, 
on  the  other  hand,  a   fatal   i^sue  in   half  of  those  attacked. 

The  unfavorable  progno>i>  of  so-called  nephrotyphoid  is  gen- 
erally rwogni/(Hl,  but  it  is  by  >ome  French  inve-tigators,  however, 
exaggerated  far  bevoiid  the  actual  degree.  Of  tin.")  fatal  cases  in  Ham- 
burir  and  I.eipsic,  -JT — I.")  ]>er  cent. — were  attributable  to  comjilicatiiig 
nephriti'.  Th.'  iinif  uTiiity  of  it-  occurrence  in  both  sets  of  statistics  is 
noteworthy:  while  of  "J  b'^.  fatal  cases  at  L.'i|)Mc,  "hath  was  due  in  11  — 
■\.(\  per  ce.it — to  iiejiliriti<.  atnonir  the  -MVl  at  Hamburg,  nephritis  was 
the  imme<bat<'  cau-^e  u(  d.ath  in  K! — 1.1  ju'r  cent.  A  ray  i>f  light  in 
the  Ldoomv  pro<rnosis  of  iie|)liritis  may  be  found  in  the  tact  that  it  it 
does  not  cause  death,  complete  recovery  generally  follows.  I<ong- 
continued  albuminuria  or  transition  into  chronic  nejihritis  is  le-s 
common  ii:  coiuiection  with  typhoid  i'ever  than  with  some  other  infec- 
tious diseases. 

Although  it  has  been  necessary  to  emphasize  the  influence  of  the 


i! 


FATA  I.    77.7M//.V.I  770.V.      IT.O<;.\(>siS. 


396 


toxin  upon  the  heart  and  tlic  vuMimcit(ir>  in  irciunil,  tlir  in<l     idnal 

(li-oasos  <>r  tlic   iiiviK-ardiuni,  the   |>iri('ardiiim,  and   the  endncardiiiiii  as 

can-cs  of  d'utli  arc  iiicon^idiralilc      The  i)ruj;iiu.«i-.  uf  iy|)linid  niycu-ar- 

ditis   lias  :•      adv  liirii    |Miiiilc<l  ciiit    as   imt    so  inil';ivoral)l('  as  it  iiiijrlit 

aiiiK'ar   troin  tlie    inllucncc   of   the  same   coiiiliiioii   in   otlicr    iiiti'ciidus 

disease-,  as,   for  instance,    in   di|(litlicria.      Sonic  si^Miifnancc   i-,   ncvti-- 

tlieless,   to   lie  attaciicd   lo    t_v|)iioid   myocarditis   in   tiic  e.\iilanatii>n   nf 

cases  of  siiild  ii   deatii. 

It  is  not  worth  whih'  to  discuss  iiidivi<hiaiiy  the  reiiiainiiif^  oi-;:iii  s  and 
svsteius  with  reirard  to  their  inriuence  upon  tlie  inortaiity  and  the  prouMiosis. 
'i'hev   are  rare  or  only  occasional   occnrriiK'cs,   and  I'o  not   reiiuire  s|)ei'ial 


Cdiiiinent.      The   liest   idea  of  the 


diti<i 


jircscnt   in  this  eonne<tion  will 


be  atforded  hy  the  followinfr  taliular   arraiitrcineiit  of  the   principal   causes 
of  death  in  5>i0  cases  observed  at   Iland>ur^'  and   Leipsic  : 


CAtsES  OF  Death. 


Sovpritv  III'  tilt"  intVctinn  .    . 

Iiitestiriiil  iiiTt'i iriit.il in,  jiiTitmiilis 

Iiilr.-limil  iicmiirrlmijf 

I'lii'iiriioiiia 

Ni'pliritis 

lli'miirrliiiiiir  iliiitlu-sis 

i*\i'niiji,  seiitic'i-niiu      

Kry.-ipi'l:i8 

Di'i'uliitu.^       

Miiltipli'  iili'icesi'i's 

Niitnii 

I'lrerativc  liirvriLriti-.  iiiM'ri>>ii»  of 
rftrtihi;;!',  iiiul  ?lm]ui'1.>; 

I'ulmiiriary  oilcinii 

Sorntibritiiiu-  oxuilHtivi-  pliMirisy  .    . 

Eiiipyema  iif  the  pli'iira 

I'yiipTii'Uiiiotliiirm    .... 

PiiliMiumry  tu'''"rcul(i>i3  ami  mili- 
ary tulllTl'Ulil.-.is 

PiilTiinnary  Ptnliullsm 

Fatty  liPart  (niyiicanliti?  ?)    .    .    .    . 

Kriliicanlitis      

Delirium  tniiiuins 

Mi^niiii^eal  tii'niiirrhHi;f 

PuruliTit  nieiiiiiL.'iti'i  witli  ciirii>  "f 
the  temporal  lione 

Dipluhoritt 

Almrtiiin  anil  premature  lalinr  . 

I'yusalpin.x.  perforative  peritntiitis  . 

Total 


lltini 

|U^^•. 

.  1 

I.ii| 

sic. 

I'tTii-ntane. 

NiimlMTof 
cases. 

I'orc(-nlai;p 

IS.; 

.M    1 

S!l 

4  J.  4 

r<\ 

11.  1 

4(1 

I'.MI 

Lil 

il.ii 

III 

I'. I) 

"ii; 

1 .-.  .-. 

L'4 

11.4 

Kl 

■1  ;: 

11 

r).2 

;> 

'J.  3 

o 

n..-) 

8 

3.  s 

4 

1.1 

'> 

o.:i 

1 

or, 

1 

(1.3 

4 

:{ 

3 

1.1 
(I.H 
(I.H        1 

1 

0.4 

3 

n.H 

1 

(1.3 

3 

(I.H 

3 

1.4 

1 

(1.3 

•) 

(i.'.i 

•) 

(I..-) 

1 

0.4 

T 

(1,3 

1 

11.4 

3 
1 

(I.H 
(1.3 

1 

(1.3 

1 

(1.3 

1 

o  t 

3(17 


4 

1 

:il3 


I.'.I 
(1.4 


With  rctrard  to  the  manner  in  which  death  occurs,  it  is 

t^caroely  worth  s|M'akinj;  in  detail.  From  what  lias  been  previously 
paid,  it  will  apiwar  that  it  is  most  frcijiiciitly  jiri'ceded  by  sym])toms 
of  the  most  profound  intoxication,  with  paralysis  of  the  h(art  and  the 
nervous  system,  and  these  are  not  much  ditfcreiit  in  cases  of  typhoid 


'■   el 

'I 

il 


.^  m 


.|^^^* 


.a  '   A- 


l^!c 


;;!Mi 


TV  I'll' II  I,  I  i:vi:i:. 


fever  tli:in  ill  iitlitr  acute  iiileetiDiis  <lisea-es.  At  later  jKTii«l~  nC  iIk 
<li-ea-e  llie  I'alal  teriiiiiiatioii  is  LTeiierally  atleiideil  witli  -\  in|ituiiis  ol' 
exiiaiisticiii  ami  nf  iiiara.-iiiu>,  (H'  lliosi'  nt"  e(iiii|)liealiori>.  Kaeli  ol'  tli( 
i'alal  local  (li.-urilLT.-  iiaiiirally  iiin>i(-ses  with  its  jiarticiilar  >taiiiii  tin 
maimer  in   wliich  (Icatli  uceiir-. 


SUDDEN  DEATH. 

Ill  '■Imlinj;  this  cliajne, ,  only  the  cases  ot"  siiddeii  death  in  the 
eiiiir-e  (iv  typhoid  I'evcr  will  he  (oii-i(lered  miiiu-*"  jiat  iiiori>  in  detail. 
'J'hesc  l.icliido  the  ca.-es  that  loniaiii  indelihly  lixed  in  the  meniorv  of 
the  jihysiciaii,  in  which,  quite  nnexpectcdly,  iliirin^'  eonvaleseetiee  of 
apparently  >atist'a  tory  pro^rr,.,.,  ilu.re  occur  Mid<leiily,  like  a  lijrlitnin<;- 
stroko  or  after  a  short  interval,  the  alar.,iiM},f  symptoms  to  wliich  the 
patient  siieciiinli>. 

As   with    s any   strikiiij;   clinical    features   which    arc    cspei-ially 

iinj)re»ed  upon  the  incniory  of  the  ]>hy-ieian.  and  are  theret'ore  more 
friH|iiently  ile-crihed  and  mentioned  in  ~tati>tie>,  >o,  with  rej^aid  to  the 
cases  ot'>iiddeii  death,  an  impre>-ioii  ha~  nncon-i'ioii^K  hceii  jruined  that 
they  are  tiir  more  frc(pient  than  they  really  are.  On  the  coiitrarv,  I 
coii-ider  their  occurrence  as  aetiiallv  iiifrei|iieiit,  and  lulieve,  in  addi- 
tion, that  it  eat)  often  he  prevented  it'  in  the  later  -tajre<  ot'  the  di-case, 
|>artienlarly  the  ])eriod  of  c(invales<'ence,  the  patients  are  carefiillv 
watched,  and  are  kept  at  list  pliy-ieally  and  nieiitallv,  and  are  not 
permitted  to  p't  out  of  IilmI  too  -ooii.  'riii>  -tatemeiit  implie~  that  the 
oases  of  sudden  death  are  lik(  ly  to  occur  esp((iallv  in  the  period  of 
deferve-cciice,  and  even  *till   'iiofe  t're(|Ueiitly  in   that   of  convalcM'eiicp. 

The  nnliu'tunatc  occiirrei i~    iiiconijiaraldy  le-s  common  at  the  heijrlit 

of  the  di-ea-e,  and  it  has  lieen  ol)>ervcd  oiilv  exceptioiiallv  in  the  fi.^l 
week. 

Tt  Would  \>o  a  mistake  to  helieve  that  easc<  of  >iiddcii  death  occur 
with  |ireferenee  in  persons  who  already  are  esjiecially  d(  liilitatcd  hv  rea- 
son of  coli^tituton,  age,  jtrevious  disease,  severe,  protractinl  course  of  the 
attack,  or  comi)lioatioii.  <  )n  the  contrary,  rohiist  youthful  individuals 
are  attacked  quite  as  often,  almo>it  still  more  freqiunlly,  even  after 
attacks  of  the  disea-^e  of  modersitelv  <evere  or  e\cn  mild  course.  This 
indicate- that  in  tlii- connection  anti'cedcnt  |iredis]Mwitioii  or  the  severity 
of  the  di-ease  it-elf  is  of  le<-  iutlueiH'c  than  certain  more  or  le-s  unantici- 
pated alteration^  that  a]ij)ear  in  the  coiir-c  or  after  the  termination  of 
the  disease. 

Mo-t  t're(|Uently  the  ca-es  of  sudden  <leatli  occur  nmler  the  fI)llowini; 
oondiiioii-:      'I'he  iiatient.  aiijiarentlv  i>reviou-lv  well,  hut  still  laiiL'nid 


/I  TM.    I'lCnMISWrinS      ri!<i(;\nsis: 


nriT 


:iiii|  weak,  cr  Willi  <ii;ii|il:iiiil  <>{  tr.in-iciit  i)al|)itMtii>ii  ni'  llif  lican, 
i\liilpiliiiL!  a  latlicr   ~iiiall,  iiii-talilc,  a. id  tic.|ii(iit    |iiil-c,  Middiiilx ,  in  ur 

iiiit  '<{'  Lnl,  ;.nii(ially  while  (■iiL':i<;id    ill  -iniic  jiliy-ical  viYxvi itiiii'.'  ii|) 

Id   take    fund,  IT   I'oi-  (Xaiiiiiialiiiii    i.r   ddicali '.r   iiidiil^iii::    iu   -li'Tt 

\valk>  <'cpiitrarv  U<  lli''  iii-iriii'tinii-.  uf  tin  pliy-iciaii — liiMuiiit-  pale  and 
coiiaitsc-,  t'alN  hack,  ami  die-  wiiliiii  a  \vw  iimmiiIc-.  H'  tin'  ]pli_v.-i(iaii 
soipii  ri'acius  the  i)atiiiil,  lie  will  ;.'ciicraily  ,-lill  he  ahl.'  Ipp  imlire  -ome- 
wliat  sttTtorous  l.realliiiii:,  while  the  jiiil-e  i-  already  iiii|p(  ne|p|ihle  and 
the  licart-soiiiuU  are  scareely  aiidihli'.  The  iiii|)res-ioii  is  jrained  that 
liie  patient  has  >iu<Minil)ed  t'>  aetiial  heari-i'ailnr  ■,  tip  whieh  cenhral 
aiiPtnia,  as  (Piie  ipf  th  •  inanife.-tatiipiis  ipf  ipimIppiiikI  Iploipd-ehanp',  ha-  ei>u- 
trilnite<l  In  share.  To  this  th"  layman  gives  txpies-imi  hy  attrihuliiiji 
death  to  cardiac  failure. 

The  oeciirroiiec  of  sudden  death  in  ms  of  typhoid  fever  has  tor  a 
longtime  licen  emphasized  in  the  literature  (("liomel,  Loiii-,'  Miirehi- 
s<pn^).  The  condition  has  U'en  more  thonpiiLdily  .-tiidied.  recently  hy 
Hayein,'  Bii-sard,'  ami  Iliiehard  ' ;  in  (iermaiiy,  >o(pii  afterward,  by 
I^evden*^  and  his  pui)il,  Miller,'  in  an  e-peeially  iKPtewcpithy  cppmiunuiea- 
tioii.  The  question  was  further  elucidated  hy  the  invotiiratiipii.s  of 
Ronil)e'rg' uj)on  typhoid  myocarditis  in  my  clinic.  These  more  recent 
pulplicatious  have  >hown  that  intlaminalory  alteratiipiis  (pf  tl'c  myipcar- 
diuin  plav  the  iiKpst  inipiprtant  rn/c  in  ihi>  eoimectiipn,  while  the  earlier 
investigators  a-sume<l  only  fitty  degeneration  with  atony,  dilatation, 
and  friability  of  the  myocardium. 

Among  the  French  writers  certain  ditferenees  have  arisen  recently 
in  that  s<pme  believe  that  sudden  death  occurs  e-pecially  ipr  exclil>ively 
from  Ciirdiac  failure,  while  Iliichard,  Bussaril,  and  in  part  als(p  Dieidafoy,' 
consider  cerebral  anemia  as  the  more  important  cause.  I  believe  that 
we  have  to  do  here  with  an  unpromising  contnpversy,  and  that  both 
factors  are  inseparably  necessary  flir  a  full  explanaticpn  <pf  the  cas<'s  in 
(luestion.  I  have  jwrsonally,  when  I  have  been  able  to  watch  my 
patients  carefullv,  ptirtieularly  in  the  hospital,  observetLoidy  a  few  cases 


'  Lm-.  rit. 

''  Jour,  (if  Mfif  Sri.,  March,  1807  "itcj  by  Hillir.  Tt  is  intcrc^tinc  and  imiica- 
tive  of  tlif  rarity  of  the  pvont  that  Miirchi-on.  witli  lii ■■  acute  powors  of  nb-iTvation, 
docs  not  even  mention  the  cases  of  siiildcii  dcatli  in  liis  will-known  hook. 

'  Lor.  rit.  *  Cited  liv  Virchow-Hirsch,  Jiihrrxhrrirht.  lS7i'..   Bd.  ii. 

'  I'ninn  mi'd..  1S77. 

'  In  his  publi<'ation  upon  tlpc  cardiac  atfcclioiis  of  ili|ditliPria,  Zeit.  f.  khn.  Mrd., 
\Sm.   Bd.  iv. 

'•  Cfinnfe-Annnlen.  Il^f^n.  Tlii- pa|icr  cotitains  :"  ■  additional  tiiMio<;raphic  refer- 
ences and  statistical  data.  *  /e.i-.  i-.^ 

»  (if,z.  hrbd..  1ST7.  No.s.  'JO  and  -J^. 


.•;;tH 


TYViioin  irvi:i:. 


I' 


III' -mlili'ii  iliMtli,  iiiiiloulili  illy  l«r:iii-f  I  ]HT!Mil  tiiv  cinivali-ii  iit-i  In  jjct 
ii|)  ciiiiiitaiMlivcly  l;ili-,  anil  rxtrri-r  |iaiiii'nlar  can-  will;  ainiiiir  |ialirnli 
wliii  prrMiii  ,-n-|iiriiiiH  aclivily  ul'  llic  lirart. 

<  If  my  t'l  w  ciincs,  tuii  may  lir  licM'rilnil  luirlly  lien-:  A  lirailliv,  \iL'or- 
iiiiH  iiiiTi'liaiil,  l«»'iiIy-i\M)  year;*  njil.  alUr  lia\ini.'  sirvcil  in  ijjr  arm\  llir  lirsl 
nini'  iMniiiii>  lit' his  trrm  of  a  \iai'.  was  ailaikrii  iluriiii:  tlir  la^t  |*-iiiMi  nf  Ins 
,-iTvii'i'.  Ill-  riirniiui  il  tn  ilia_'  lum.-iir  aluml  lor  ihf  lii>l  un  k.  Iiijl  iluriiij; 
llir  liillnuiiiu'  "fi'k  \\a,>  inir-iMl  in  ilic  la/ari-tli),  ami  .luliM-inicnlh  al  Immr. 
Ill  iIm-  t'uurlli  Wfrk  111'  ua>  I'lri'  t'riiiii  l'i\rr,  liaij  a  i/uml  aji|iflili',  aiiil  wa>  in  a 
riinli'iilcil  t'rainr  III'  miml.  .-n  lliat  tin'  |ialunl  ami  liis  tVii-mis  coiisiilcrril  it 
|H'iianiii'  that  1  t'urliailf  lii.-  L'lUini,'  np  aliir  luilvr  al'i'lirilc  ilavs  liail  |ia.-.-cil. 
.My  |irniiiliiiion  ua.s  lia.-nl  iiimn  llic  I'ait  that  tin'  jialifiit,  in  fpilc  nl'  (.nh- 
iiiiriiial  toin|ifraliirr,  siill  ninliiiUfil  to  ixhihit  a  miI'i,  now  ami  a^'ain  itilcr- 
mitlt'iit.  |iulsc  iif  iiinrc  than  ><0,  ami  at  the  same  lime.  \\  ith  rltar  hul  taint 
hfart-siiumls,  cxhihiti'il  the  >i'_'ns  ol'  slitrht  ililalalimi  of  the  niviuanlinm. 
On  the  fuiirli'i'iith  ilay  nf  lunvah  M'cmf  the  nnrsi-.  rutaintil  hy  im\  (liiccliori, 
(in  rrtiiniin;,'  tn  tin-  rnoin  allrr  an  aliM-ncr  nf  scarct-lv  ten  ininnus.  fmiml  the 
|ialiiMii  lyin'.:  in  frmil  nf  ihc  linl,  nmniiM'inu-  ainl  |inl.-(li->s  ;  anil  lirfnrc  >ln' 
ua.-  a  I  lie  In  siuniniin  asM^lanrc  the  paliftil  was  ilcail.  A]i[iai(iit  Iv,  tin-  patient 
hail.  riinlrai-y  In  inslrmiinn.-i.  i/ni  nnl  nf  In  li  Inr  the  purpnx'  nf  uriualiii^. 
l'ii>l-tniirlfni   I'.vaminalinn    \\a.-   nni    piTiniltfil. 

Tlic  sci'iinii  ci'M'  is  cspcriallv  nntiwnrlhy.  1  tcansr  I  was  prrscnt  when 
(Icalh  nrciirri'il.  Thf  paliint  was  u  wmuan.  thirlv-diii'  viars  nlil.  who.  alicr 
a  iniiiliralt'ly  si'Vcrc  attack  nf  lyphniil  fiver  of  iiiur  weeks'  chiration,  wilhont 
ciiMiplieations,  hail  lieeii  free  from  fever  for  five  ilavs.  The  pulse  ranL'eil 
from  DO  to  loo  in  the  iimrninL'.  up  to  112  in  the  eveiiinj:,  was  mnck'ratelv 
full,  tense,  ami  reLTular,  Imt  slill  (piite  varialile  in  frei|iieney,  so  that  linrin:.' 
speakin;:  or  on  sliLrhl  movements  after  ealiiif,  at  limes  also  without  extra- 
neons  cause,  the  frei|iieiicy  wa.s  increased  from  Id  to  nil  heals  a  minnle. 
The  area  of  cardiac  iiulness  was  appar(iitly  nnrm.'il  :  the  snnmls  wen-  ilnll 
and  faint:  no  nnirinnr  was  aiidilile.  1  had  examined  the  ]ialienl  at  llie 
mnrnin'_'  visit  and  had  limnd  nolhini.'  w  rnii;:.  and  al  her  rii|nest  had  even 
onlar'.Teil  the  diet.  After  I  had  L'ot  a  dislaiice  of  three  heds  awav  I  was 
rei'alled.  'l  i.  •  patient  had  sat  liji  and  had  reached  for  a  letter  w  Inch  had 
heen  receivid  .he  evenin;.'  hilnre.  and  which  we  snli.-ei|neiitly  liiiiml  to  he 
of  an  exciliiiL'i'h  iracli  r.  had  siiddeidy  heconie  pale,  and  had  fallen  hack  npoii 
the  pillow  unconsiinn-^.  ."^carcelv  a  minnle  elapsed  hefnre  I  saw  the  patient 
aL'.'iin.  linl  her  fialiircs  were  already  relaxnl,  the  pnpils  were  dilaled  and 
fixed,  the  pnlsi-  was  iin  IniiL'er  perceplihlc.  aiid,  after  a  few  slerlnrous  hrealhs, 
di'Mlli  had  taken  place  willmnt  cnnipl.Mini  nr  snijnd.  I'lL-l-mnrliin  exandna- 
linn  iliscln>ed  nnmcmiis  recent  cicatrices  in  the  Inwer  pnrlinn  of  the  ilcnm 
,'ind  the  adiaccnt  pnrlinn  (i\'  the  larL'e  inlc.-line.  The  hrain  anil  the  hint's 
exhiliifed  nn  pecniiarilies.  The  heart  was  innderalelv  dilated  and  relaxed. 
The  mvocardium  was  vellowish  'jrnv  in  cnlnr.  t'rialile.  and  liritlle.  Mii  rn- 
scopie  exannnalioii  disclnsed  fall v  dcL'cneral inn  and  scL^nienlatinn  nf  iherniis- 
ciilar  lilires.  with  partial  niijiteralinn  nf  the  transverse  .-Irialinn.  The  case 
was  nhscr\cd  a!  a  time  when  thornni:h  microscnpic  invesliLralinn  nf  tvphnid 
mvneardili>  was  not  tnade.  Imt  I  have  no  donht  that  the  cnndilinn  was  of 
this  clh'iriicler. 

[n  aililiiii'ii  tn  niyiicarilitic  ])afalv-i~  of  llie  heart  ami  cei-elir.il  aticmia 
as  a  can-e  nf  sinlileii  ilealli,  pulnmnarv  enilmli-m  iiinlniililcilK-  alsn  phivs 


i-Mii.  riinn\.\ri'i\     ri:n(;\iisrs. 


.'WO 


an  iiii|M>ttaiil  /■:/..  '\'\\<  >iiiU.li  :uv  .l.iiv.-.l  i>i  [.art  In.m  llir  rrnhial 
-iiiu-i-  ((iiii  — iiii.rir)  ami  tlir  |Mriiilirral  vrin-.  pail  i.  iilarly  llii».>  of  ilic 
iMiviiiiti.-,  anil  partly  fn.m  llic  iii:lil  -i<l<-  nt'  tlir  litart.  Marvaml  ' 
iiii(l>iiilil.dl\  i:cii-  I'M.  tar  ill  allriKiiliiii;  lln'  iii;ij"rity  ..I'  all  i-im-  ot'  ~ii<l- 
.1,11  .lialli  \n  raidiar  tlii"inlM.-i-.  i'ln  n|M.rl-  ..I'  lii-  ouii  aiilnp-i.-: 
^liow  tliat  ill  aiMiti^iii  I"  tliiuiiilM.-i-  lliiif  wa-  prc-.iil  pn.r.iiiii.l  .liv.iic- 
ralinii  III"  ilir   iii\  ncanliiiiii. 

Mil.  Ii    l.»  .nmiii.'ii   lliaii    piiliiii'iiarv  ,iiil".li-iii  a-  a  caiix'  >d'  -ikI.I.  ii 
.l.ath    i-   .tiilx.liMii    .if   ill.'    ..r.  I>ial    arl.  ri.-.       I    liavc    pivvi..ii-ly    iiicii- 

ti,,ii...i  a   .a r  iiiv  i.wii  ilia-ilar   ari.r.  )•      1 1.  iii..riliai:i'    int."   the   ^lll>- 

>taii.c  i>{'  the  Kraiii  ami  llir  iii.'iiiiit^r-  i-  iii.t  iimr.'  .11111111.111.  It  .i.ciir-  in 
.■a-c-i  111"  till'  li<'iii..rrlia-ii'  vari.ly,  a-  "ill  a-  n.iu  ami  lli.ii  in  al.'..li..li.' 
palit'iil-. 

Till'  \i.'\v  iiiaiiilain-.l  liy  a  (".'U    l'"i'iii.'li  iiiv.-tiLMl"r-,  that  .l.alli  may 

rc-iilt    ill   .•oii~c.|ii.i t'  -lid. I. 11    pi'.'iiliar    iiil.'ii-ili.'atioii  ..t'  lli.'  lyplioi.l 

int.-xi.-ati.iii,  is  f..r  tli.'  pr.  -.iit  uitli.nit  linn  -iipp.Mt.  N..tirniL',  also,  ot 
a  ilcfiiiitf  rliaractcr  lia~  a^  y.t  hi't'ii  .lt'im.ii-tral>'<l  tor  iitli.r  t.ixi.'  condi- 
li.iii-,  as,  li.r  ill-tan.'.',  iir.iiiia  .aii-iiii:  ap.'pl.'\y.  I'll.' vi.'w  ..t  !  )i.'iilaliiy, 
that  il.atli  iiiav  h.' i'au-..l  liv  ntl.'X  -pa-iii  in  ilw -irii.tiin'>  iiintTvatfd 
i'ri.iii  til.'  incliilla  .il>l.Mi;:ata.  parti. iilaily  1>\  lli.'  pmiim.iirastric  iitTvt, 
cx.'it.'d  hv  the  .lis.asc.l  int. -tine,  is  liaM'.l  .'--(iitially  M|m.ii  the  fa.'t  that 
in  til.' I'l'Mical  .ih-crva'i' •'>  ii|)iiii  wlii.li  tlii-  vi.'W  i- liaxil  l.ical  altora- 
tinii>  .if  an  explanatory  i'liara.''.r  wife  not  t'.iiiii.l.  The  theory  has,  so 
far  as  F  kn.iw,  r.'inaineil  without  -iipporter-,  an. I  has  lieen  restricted 
ami   altered   hy  its   pr.m    dilator   in  a   later  .'.ininiiiiii.ati.in.^ 

•  Thist,  I'uris,  18C',ii    Vinlmw  >  .AiA/f.v'/ficA/,  18t;;i.  lid,  ii.  *  Loc.  cit. 


III.  DIAGNOSIS. 


;.».^' 


!ilM 


l|!l 


lil;i 


'I'm:    iilr.ll    rnctlH"!   "I'   i|i:ii.'ll"-i-  of    |\  |i||i.|(l    I'lAi  I-   U  III  I  111     lie    I  llr  ililll- 
iill-l  ml  ii  Ml    xsilll    liaililii--,    l:l|iiilil\  .   :ilii|   ri  rliilllN    nl'    it  -  rall-c,   I  In-    li.iiil- 

lii-  111'  llliii'ili.  iliiiiiii:  iMix  iiiriml  lit'  till  ili-i;i-r.  I  Ml'iirtiiii:itrly,  ilii- 
liicp-l  fjatillal  iiii'IIiimI  i-  nn!  \i-!  a\:iiialili'  in  a  ilr^nr  al  all  a|i|iriiacliittLr 
|)rrlrcliiiii.  (^iii-I  iiiii-  liavr  at  linn-  i\in  linn  iai-i'<i  a-  In  llir  [«i--i- 
liililv  III' <li-!ini:ni-liin;r  llir  lv|iliiiii|-liaiillii-  t'lmn  "llnr  nriraiii-in-  (I'lijnii- 
liai  illii~  L'i'iin|i)  ri-inililin;.''  it  iiiiir|ihii|iiirii'ally  mil  liinlnj.'-icallN .  I'.ut 
|ii-ilav  ur  Uliiiu  llial  il  lia-  di  llnilc  ami  |Mciiliai'  iliarailrri-lic-  wliii'li 
<li-tili^rili^''  it  tViiin  all  uiIh  i-  uriiani-in-.  Inirino-I  anmn!.''  tlir-c  -[xcial 
IralUri'S  is  its  -|m  rilif  narli'ill  In  I  lie  I  ill  II  k1  anil  tlir  liiiil\  -lllliil-  nf  Iy|iliiii(| 
patients  ainl  iiiunnni'  animal-.  TIm-i  |  ir-ml  rnilliuil-  nt  (li-tiiiL''iii>liinn 
tlii-  iifiruiiisMi,  hiiNMVir,  wliilr  rrlalivcK  -iin|ilr  !■  '■  tlif  r\|i(rirniTil  liac- 
t<riiili)i:i-t,  priMiit  nui-iidinilil.'  ililliriiitii-  lin'  ihr  in-aciiliuiicr.  itiit 
!i-ii|i'  t'nun  till'  iilintiliiatinn,  it  i-  imt  an  intinis  la-y  ta-k  to  i-i.latr  tlic 
urvani-in  ilirnlK  tVniii  iIk'  paliiTit  nr  lii-  -i  firlimi-.  The  nirlliiHl-  arc 
(•■iii-taiillv  licili;.'  -iin|ililif(l,  Imw  t\  i  r,  ami,  u  liiif  imaiis  afc  :l\  ailalilc, 
ciillnn-  tVivin  tlir  iirini',  ti(r<,  111-1--1M1I-,  ami  r-|Hrially  tlic  MihmI,  arc 
f|-ii|UiMitlv  111"  tlic  ;:i'calr-I  aiil  in  iliatriin-i-.  Later  wnrk  witli  newer 
Ilielliiiii-  lia<  -Imwn  tlie  |ire-inee  nt'  ty plmiil-liaeilli  in  the  eireillatillj; 
liliMiil    in  7n  tn  sii  |m  r  leiit.  nt'  the  ea-o.  I'rei|iienlly   (|iiitc  early    in    tlic 

(ii-ea-e  ;    ailil    't     i-    In    lie    linpeil    tliat     t'lll'tlier    iinpruVCinent-   ill   llietlinils 

iiiav   iiiakc  the  ileninii-tra'i I' it-  cnii-laiit  pre-eiiee  pi(--il.le.  ami  make 

the  nii'thnii  reailiiy  availahle  I'nr  elinieal  piirpn-e-. 

The    methnil    iA'    -eriini-iliaLTIln-i-     maiie     |)n--ilile    liy     tile     lalior-     nf 

rt'eitl'iT,  (inil.er,  ami  Wiilal  ha-  heen  -huwn  l.y  a  lar^'  iiiiinlicr  nf 
repnrt-  ami  hy  it-  aliim-i  luiiver-al  ii-e  at  prc-eiit  tn  he  nf  e|-cat  alil 
ill  liiairnn-i-.  even  thmiLrh.  nii  accmint  nf  the  very  frei|ileiilly  ilelayHl 
aiipcaniiK-e  nf  the  nai  tinii,  it  has  imt  pmveil  tn  he  nf  ijiiite  .-n  mueli 
(liairiin-lie   value  a-   \va-  at    lirst    lin|«'il. 

lint  hnwiver  vahialile  tlie-e  Tiiethnil-  nf  haeterinliiL-'ic  iliaL'ii'i-i-  tnay 
lie  in  eertain  ea-e-.  il  mii-t  he  cmiilia-i/eil  that  at  jircseiit  nli-ervatinn 
at  the  l,eil-i,le  -till  retain-  the  first  place  in  ilia;rn"-i^-  ''  wmilil  he  a 
Serinll-  hliiW  In  the  further  develnprneilt  nf  nlir  elillieal  kllo\vle<l}re  it 
the  fnriner  methnd-  shniilil  di-plaee  careful  irciieral  and  vi-eenil  cxaiiii- 
iiatinn.      I'.ut  ju-t  a-  little  a^  cxplnratnry  puncture  nr  even  exploi-atnry 

JUII 


hi  M.MiSIS 


101 


<•(  liiiti.iiiN  i-  liki  Iv  til  n-lriit  lliiiriiii.fli  rliiii(".il  invi-tiiritimi,  -n  littlf 
al-i>  i~  il  iiriiliiilili'  tliMt  llii'  liMilrriiiliiLrii'  iiirlliuil  \niI|  cm  r  Ik  tlir  •  mIii- 
>ivi'  mil'  ill  tlir  iliauii"i~i-  nl    iiilf<tii>ii«  ili»<-a>i>. 

'I'liiTf    iirt,  liHWi  \  I  r,  rtrt:iiri    ra-c-.    in    wliiili    llic    irm^l    -kilt'iil    ami 
jKiin^taklnu'   rliiiiial    -liii|\   aluiir   laiiiiiil    iiiaki-   a   ri-rlaiii   iliairnii-i^,  liiit 

wllilll   lliav    iiricri     lie    ill  lillili  1\    iliiiilnl     li\     liaili  liiiliiiri''    Mltlliml-.         I'lic 

riiiiliiir  ii-f  111'  lalmialiii  \  iiuiIh"!-  w  liiinvcr  pn— ililr  I'aiiiinl,  tlicnrurc, 
1)1'  tun  »tiiiiitrlv  iiririfj  if  ail  aci'iirati    aihl  iiilaiii  ilia^iiu-i-  i«  !■>  !><■  liiailr 

in  all  rax-.       I'liiv  ilu  imt  ami  rat t   lakr  llir  |ilaii'   nl"  lanl'iii   iliiiical 

iili-crvatinii,  Imt  iiiii.-t  l>c  nixanliil  -iiiijily  a>  aiil-  ami  aiiiv-Miry  t'aiturs 
ill  arriving;  at  (liat;iiii«li iii|ii,-ii>ii>. 


CLINICAL  INVESTIGATION. 

Ill  arn mlanco  witli  (lio  flirc^jniiif^  jmiii!  .if  view  we  |(liict'  clinical 
iiivi-ti^pitim  II  ailvaiicf  nf  tlic  liactfriilnf^ic  iiictliiMl.s.  Altlmujrli  vc 
have  III!  kiin\vlt'<lf^e  as  yet  nf  any  cliiiiial  -ij^'ii  nf  ty|>liniil  ti'vcr,  wliicli 
is  in  it.MJf  cniicliisivt'  I'min  the  (liaf;iin:^tic  staml|Kiiiit,  tlitTc  arc,  mvcr- 
tlit'ltss,  a  iiunilxT  nf  -yniptnnis  that,  j.'rnu|if<i  in  accnnlam'c  with  the 
iiiaiiiKT  and  time  nf  their  ajijM'araiicc,  tluir  >c<|ii(ii<'c,  and  thi'ir  as.s<i- 
cialinn,  may   admit   nt"  alnn  »t   cnmiilftc  dia^'mi>li<'  ctTtaiiitv. 

The  diaj^nnsis  nf  typlmid  fcVcr  is  liy  nn  m(aii>  ditliciilt  if  a  nxse 
|)iir-iiiiif^  a  typical  cniir>c  I'aii  tu'iihscrvcd  at  tiic  outset  and  fnr  a  cnnsid- 
cralilc  time ;  and  if,  in  ailditimi,  mic  is  iutnrmcd  with  npird  to  the 
remntc  and  the  immc<liate  circmiistaiu-es  atteiidiu);  its  develupinent. 
Tile  sitiiatinii  Ix^Mimes  tar  mure  ditficiilt,  linwc\  cr,  if,  in  the  aliseiicc  of 
knowh^lfje  of  the  antecedent  cnnditiniis,  a  deei  ion  must  U'  rcaelKil  at 
once  or  after  a  slmrt  pcriinl  nf  oh-ervation,  and  if  the  ca.«e  is  seen  only 
at  a  later  stafje  nr  if  the  attack  is  an  alilireviatiil  niie  or  one  pursuing  a 
wholly  atypical  course. 

It  is  jiiirtieiilarly  aoteworthy  and  always  to  he  kept  in  mind  tl'Tt 
the  soH'idlc'l  typhoid  state — that  ^ymptoiii-coiiijdcx  that  formerly  oceii- 
]>ie<l  the  mn>t  |)romincnt  po>itinii  with  rc^.^jird  tn  the  rccnjrnitinn  of  the 
<lisca>e — has  Inst  mnrc  and  nmrc  of  it.-  dia^'iiostic  sijriiitieance,  and  that 
at  the  jiresent  day  it  is  reeogniztHl  to  liavc  licci.  an  oli^tacle  to  diagnostic 
progress  in  the  past.  At  the  present  day  it  can  mily  liesjiid  that  an  indi- 
vidual presenting  the  ty]>iinid  >tatc  liasheeri  ti>r  some  time  and  in  severe 
degree  ex|)nscd  to  the  iiiflncncc  (nf  the  tn\iii»)  i>f  an  acute  infi-ctinns 
dise^ise  ;  whether,  hnwivtr,  tlii-  is  typlmid  fever  nr  sniiie  acute  diM-iis«", 
as,  fnr  instance,  tyjilius  fever,  septicemia,  meningitis,  or  miliary  tuhcr- 
culo-iis,  is  a  (juestion  for  further  c-.ireful  consideration. 


i  i. 


Tl. 


2« 


T-'^ 
M 


3:'-', 


402 


TYi'iinii)  1  i.vr.n. 


ti)  he  taken  into  con.-itl'T.ition   in   tliis  o.nnoction  arc  tlic  char.iotor  of 

til,.   t'.liriU nisc,   particularly  the  character  ul"  tlic  tcnipcniinrc-  and 

j)iilse-ciirvc-  and  tlicir  rehitions  to  eacli  otlicr,  tlie  acute  enhirjrenieiit  of 
tlie  sjjlecn,  tlic  appearance  of  a  peculiar  ro>eolou>  eru])tion,  and  tlio 
<'l>ar;icter  nf  tlie  stocils.  Next  in  irnporiaiicc  are  lironeliitis  and  pul- 
monary livpo.-ta.-i~,  the  .-tate  of  the  IjIoihI,  e,-pecially  of  the  leukocyte.-^, 
and   the  demonstration   of  the  diazo-reaetioii. 

With  re^^ard  to  the  course  of  the  temperature,  the  character 
of  it-  a-cent,  in  the  well-known  -tep-like  manner,  as  a  result  of  which 
the  heiirht  of  the  fever  and  the  lM;:iiinin<;  of  the  fa-tij,'iiun  are  ri'aclicd 
in  the  cour.-e  of  three  nr  four,  at  luo-t  live,  day-,  may  he  of  ^rreat  weiirht 
in  t!ie  differential  diat:no.-is.      Scarcely  any  ..ther  infectious  di -ea.se  to  lie 

taken  itit nsiderati"n  exhil.it- llii-  mnile  of  (in>et.      It  is  trui'  that  the 

contrary  condition — iapi<l,  uniuicrruptcd  elevation  of  the  tem]>erature — 
•Iocs  not,  a-  ha-  already  lieeii  seen,  exclude  typhoid  lever,  althoUirh  it  is 
fir  more  freipieiitlv  oli-i'rvcd  in  conneciioii  with  oilier  infection-  di-- 
e;.-e<  or  with  incomplete  ah'oreviated  ca-e-  of  tyjilioid  fever.  If  one 
hears  \VunderrK'ir>  rule-  .Icdartd  -chematic  l>y  m>'iiilier-  of  the  yonntrer 
.rcncration.  ihev  -hould  he  made  to  undei-laud  that  he  was  1.—  familiar 
with  the  afehrile  and  the  incomplete  varietie-  of  ilic  di>ease,  with  re.<rard 
to  their  course  and  fre(piency,  than  we  are  at  the  pre-eiit  day.  and  that 
lie  wa.s  correct,  now  as  then,  if  hi-  conclu-ioii-  are  apjilied  to  the 
moderate  and   the   -evere   complete   ca.-e-. 

That    the    fa.-tiirium,    with    it-    peculiar   tcmi)erature-coin-.-e    ot    con- 

tinue<l  fever  or  remittent  < tinned  t"ever,  and  pariii'iilarly  its  duralion, 

niav  liedec'^ivc  in  dia^'iio-i-  need  he  hut  airain  mentioned  at  tlii-<  point,  as 
this  siil.ject  has  heen  di-cu-cd  in  previous  cliajitcr-.  The  mode  of  d<>fer- 
VescelK'c,  in  the  lorin  of  the  cliaracleri-tic  steep  .iirves,  may  also  lieVe  he 

referred  to.      In  addition,  it  -I Id  he  pointed  ..nt  that  when  the  di-ca-e 

pur-ue-   a  mild   i'.,ur-i'  and  at   a  .ertain   a-'c,   c-iiecially    in   cliildh I. 

\v\-y  carlv  remi-ion-  and  intermi-ion-  in  the  temper  'ure-curve  -hould 
arou-e  Mi-piciou  of  ty])lioid  i'e-er  ;  however,  tin-  i-  ti'ie  al-o  of  -evenil 
other  di-ea-.-.wiiich  in  oihe--  iv-|iect-  enter  into  con-id.>ralion  in  the 
ditfeivntial  diaj^iio-i-.  The  >uhiiornial  temiieraliire,  which  alnio-t  cin- 
stantlv  and  f >r  a  cou-idcrahle  time  f.llow-  deferve-eenee,  i-  alMi  to  he 
l)orne  in  mind  in  llii-  conn.rti..n.      .Mthou^i  i"  it-elf  it   indicai.-  only 

r verv  from  a  <evere  dehililalini:  int'eetiou-  di-ea-e,  in  no  oth-r  di-ea>e 

dor-  it  appear  -o  constantly  and  i-  -o  per  intent  a-  in  ca-e<  of  typhoid 
fever.  That  the  tempenitiire-curve  may  he  irreirular,  vai'iahle.  and 
whollv  uncharacteri-tic  in  tin-  various  ineomiilctc  firm^  of  the  di-eM>e 
has  likewi-e  heen   fully    poiiiteil  out    pn  viou-ly. 


■:r^r  •':•  ..    _._ 


■L.''-,v).  ■ 


,>\f    .  J'C-' ' 


])l.\t:.\()Sfs. 


40:] 


The  character  of  the  pulse  is  nuU'Wortliy  on  aocoimt  of  its  sl<.w- 
ncss,  L'.s|M.fially  in  yoiitlifiil,  vi^rurous  nuilcs.  Its  r(iiwi-kal)li-  sIowir'ss 
i,]  coiiiparison  to  tlic  liciVlit  of  tlic  tciiUHTutiire  d(K«  "ot  (Hvur  aiivwliere 
nearly  so  often  in  any  otlier  .li«case  to  Ix.'  taken  int4.  consideration  from 
the  -tamlpoint  of  (lill'erenliai  diafino.sis.  Even  tiie  slowing  of  the  pnlse 
atten(h'iiLr  hasilar  meninwitis  is  readily  to  U;  distinfrnished  from  that 
of  typhoid   fever  by   the  time  and   the   nuKJe  of  its  appearance. 

The  dicrotism  of  the  pulse  is  also  of  diaj,rnostie  sijriiiiit-aiiee. 
It  is  nnieh  more  e((inmon  in  eases  of  typhoid  fever  than  in  ail  the  other 
infections  diseases  taken  toir,.t||,.r  ;  it,  dccnrs  in  typlioid  fever  especially 
in  ])ersons  in  the  l.loom  of  youth,  in  laK'r  cliil(llio(«l,  and  even  in  oldiT 
individuals  who  have  not  too  marked  ehanp's  in  the  walls  of  the 
arteries.  If  hoth  |)henomena,  slowinj;  and  dicroti-m,  are  ol)>,.rved 
top'ther,  this  fact  may  materially  strenj:theu  the  .liairuosi>,  even  in 
ditferentiation  from  basilar  meninjritis,  in  which,  in  a.lditiim  to  slowing, 
dicroti^tn  is  scarcely  ever  oi)served. 

'I'he  State  of  the  spleen  is  of'  dia.rno-ti<-  value  if  its  acute 
enlarirement  is  observed  to  occur  towanl  tiie  end  of  the  first  or  at  the 
ix'irinning  of  the  second  week,  after  the  sli^p-likc  ascent  of  the  tempera- 
ture-curve has  tak.'U  place.      In   no  other  acute  infictious  <lis(.as(.  is  the 

oecurreuce  ,,i'  cnlarjxemcnt  of  the  spleen,  e>i ially  at   the  time  stated, 

even  ajiproxiuiately  so  fn(pieut  ;  and  in  none  does  this  condition  persist 
so  l,,ujr_into  the  third  or  the  fourth  week  .,f  the  disease,  ami  perhaps 
lonuvr.  It  is  eomparalively  rare  for  the  cularj^ement  of  the  spleen  to 
ap|)ear  befbrc  the  becriuuini:  of  the  fever  or  duriujr  tiie  very  fir-t  davs 
of  the  di-ease,  and  this  di-.tiui,'uislies  typlioid  fever  from  tv'phns  fever, 
and  from  tlie  acute  e.xantliemat.i,  f,,  wiiich  lypluis  is  clo,elv  related,  if 
these  disea-es  should  ever  be  attended  with  any  cnlaru^ement  of  the 
S|.l.'en.  Tlw  state  of  the  spleen  diM-iui,'  nOap-es  i-  also  notew,,rthv. 
The  per-^istenee  or  lli(>  reappearance  ,,f  its    idargenient  after  th-  primarv 

'''■'''■''^'•■^'■''' *'*'"•  fever  is  indicative    ,f  an  iiupendiug  relap-..,  and  aids 

indistinirui-liiuirit,  if  it  d.v.'lop,  fn.m  tibrile  conditions  of  utli'er  oriir;,,. 
Ahhouirh  the  typhoid  stools  possess  no  ,,uality  that  is  peculiar  to 
them,  nevertheless   their  color,  their  watery  character,  with   the   result- 
ing  tendency  to   the   fbrmatiou    of  layer-,    the  yellowi-M,  di-intcirrating 

f*^''!'""'"*-  '' ly-tal-.  tlu'   p.iietratiug  odor,  togetlwr  with   the  n'lativ  ■ 

infre.|ueucy  ,,f  the  di-charges  are  offu  (|uile  di-tiuetive.  It  is  true 
tliat  the  diarrhea  is  Ics,  constant  than  the  eularg<.ment  of  the  spleen. 
It  has  already  Ixm  -.■en  that  scarcely  ,.ne-tlnrd  of  all  <'ases  exhibit  thin 
stoMJ-  f,,r  a  consid<>ral)le  time,  while  not  a  few,  on  the  contrary,  are 
even  attended  with  per-i-tem  constipation. 


.WL.-..uA 


m 


If^ 


■.^.- ^^- 


-C  > wV'^' 


will' 


404 


ryriiiiii'  ievi-ii 


I)i;i<rii(istic  -i-Mitic:iiicc  i-  to  !..■  :iiI:icIum1  :il-n  to  tlic  (xriirniuv  nf 
meteorism,  wlii.li  likc\vi~f  is  Ia  ik.  mcaiis  H)  tr.(iiKiit  a-  Mviiie 
ImUcv.'.  It  i~  tnu'  lliat  it  is  -raivily  .lipfiKli'iit  diiHctly  iipnii,  or 
f^tand-  in  any  otlur  relation  to.  tlic  nlc.ratcd  state  ..f  the  Uiwel  ;  l>iit,  on 
the  otiier  han.l,  it  is,  a-  lia-  already  Ix.  ii  jxiinte.i  out,  merely  a  reMilt 
ot'  tlie  inlliieiiee  of  the  toxin  upon  the  inti  nal  wall.  A-  it  may 
develop  in  a  similar  manner,  ahhou>;li  le>-  eommonly,  in  tiie  eour-e  of 
other  aeute  infectious  disea-es,  e>peeially  pyemi.'  proecsses  and  jreiieral 
miliary   tuU'reulosis,   it    ma\  at   timo   ev.ii    iiierea.-e   the   ditlieulty   of 

diairn"sis. 

The  ino-t  siirnifieant.  almost  speeitie.  manifestation  i^  the  roseoloUS 
exanthem.      Only  with  extreme  rarity  and  only  in  a  few  other  dis- 
eases do  eruptions  oeeur  that  ean   seareely   he  distinpiishiHl  from  the 
typhoi<l   roseoho  even  hy  an  expert.      IVrHUially,  this  lias  occurred  to 
liie  exceptionally  in  cases  of  a.'iite  miliary  tiiherculo-is,  and  it  is  rei>orte<l 
also   by    reliable   writers    with   rejrard  to  cerel)ro^pinal   meiiiiijritis  and 
trii'hinosis.      In  addition,  the  rosttilous  ernjition  i>  amoii^'  the  principal 
l<;iis  of  tvi)hoid  fever,      .uost  the  most  fre«iueiit — l)y  far  more  c.mstant 
than  the  alter,.!  state  of  the  howcls,  perha]>s  even  than  of  the  enlarjre- 
mcnt  of  the  spleen,  and  at  any  rate  is  in  jieneral  more  readily  and  more 
certainly  rcrojrnizahle  than   the  latter.      If,  in  addition,  the  time  of  the 
first   ai>pi-aranee   and    t'lat  of  the   disippearauee  of  the   roseola-,    thtir 
apiHiifance  in  (soj)-,  their  characteristic  distribution  uih.ii  the  Inxly,  and 
the  short  duration  of  the   individual   crtlorescence  betaken  into  consid- 
erition,  thev  may  be  considered!  as  one  of  the  im)st  valuable  si^rns  of 
typhoid  fever,  an<l  all  the  more  so  as  their  occurrence  and  the  ilejiree  of 
their  development  are  not  pii.jx.rtionate  to  the  severity  or  the  mildness 
of  the  cases  ;  so  that,  es]«'cially  in   tlie  atypicd   cases  ditticult  of  diag- 
nosis, a  distinctive  criterion   is  at   times  thus  atlbrd.Kl. 

Crystalline  miliaria,  althouirh  one  of  the  most  fre(|uent  cuta- 
neous U-ions  of  typhoid  fever,  is  far  less  significant  from  the  diagnostic 
standp.int  than  tlie  ros.s.he.  The  circumstan.v  that  it  ai)peai-s  nlatively 
much  later  than  tlie  latter,  and  with  .listinctly  greater  fre.iucn.'y  in 
severe  a- 1  otluTwisc  tyjiieal  caM's,  exphiins  thi-  fact.  In  addition,  it 
occurs  bv  far  nuieh  more  freciuently  in  other  diseases.  I  have  observed 
it  rather  comm.  iily.  especially  iu  acute  septic  states,  typhus  fever,  and 
miliarv  tuberciilo-is. 

The  negative  rnic  taken  by  herpetic  eruptions  is  worthy  of 
mention  at  tlii^  place.  Alnio-t  all  experienced  writers  are  in  agrecm<>nt 
that  facial  herjies  occurs  so  riircly  in  typhoid  fever,  even  in  the  first 
febrile  period,  that    its  ajipcaraiuv  in   the  initial   stage  of  an   infections 


DrAaxo.srs. 


405 


iliscasc  (if  (linil)tfiil  clianictcr  is  ajpiinst  its  hciiiir  typhoid.  EsjwH'ialiv 
cortaiii  diseases  that  arc  ot'tcii  to  he  most  farctnlly  considcnHl  in  the 
(hfTcrciitial  diajriio>is  ot'  t_v|)hoid  ("ever  in  tlic  initial  stajrc — viz.,  jnu'U- 
nioiiia,  (•(•rchrospiiiai  iiii'iiinjritis,  typhus  li'vcr,  inahiria,  and  others — 
are,  liowever,  eharaeterized   l)y  tlie  freipieiiey  witli  which  heri)es   >eeiirs. 

The  diajiiiostie  sigiiitieaiiee  ot"  typhoid  bronchitis  is  not  in<'on- 
sidenihle,  and  n]H)n  this  I  place  enipliasis,  in  contradistinction  to 
other  writers.  AUlioiijrli  it  ]>resents  notliini;  characteristic  as  an  indi- 
vi(hial  symptom  and  attends  all  other  jM)ssihle  infections  diseases,  and 
some  even  in  special  dei;ree,  it  may  he  a  valnahie  sij^n  in  the  not 
infret^ueiit  cases  in  which,  althouj;h  the  e.xistence  of  a  febrile  disease 
lias  been  determiiied,  other  symptoms  distinctive  either  of  typhoid  fever 
or  of  some  otlier  infections  disejise  have  n( '  yet  lieen  recognize<l.  The 
occurrence  of  ditfusc  bronchitis  at  the  end  of  the  first  or  the  bejfinning 
of  the  second  week,  i:i  spite  of  the  abrence  of  othei  pronounci-d  sym{>- 

toms,  indicates  the  preseiK f  a  severe   infections   jirocess  ;   and  under 

such  circumstances  the  probability  that  it  is  tvphoid  fever  is  most 
likely. 

Among  the  .symptoms  that  have  recently  been  re<'()gnize<l  to  jxissess 
diagnostic  significance  the  diazo-reaction  may  ne.xt  be  considered. 
It  lias  been  sivn  that  it  occurs  almost  always  in  cases  of  tv]>hoid  fever 
in  children,  and  in  adults  also  in  the  vast  majority  of  ea.ses,  and  gener- 
ally, in  addition,  early  ;  and  even  in  relapses,  after  having  j)revi<nislv 
disappeared,  it  is  likely  to  reappear.  Unfortunately,  the  reaction  is 
jiresent  almost  as  constantly  in  eases  of  acute  tubercidosis,  ]>articiilarlv 
miliary  tuberculosis,  pneumonia,  certain  acute  exanthemata,  malaria, 
and  ty[)hiis  fever,  so  that  it  ac(piires  decisive  significance  with  relati%'e 
rarity. 

More  impirtant  is  the  state  of  the  white  blood-corpuscles  in 
typhoid  fever  (see  p.  172).  S)on  after  the  beginning  of  the  fever,  and 
progressively  from  this  time  on,  there  ooeiirs  an  often  considerable 
reduction  in  the  number  of  wliite  bhxxl-fcorpuscles  ;  this  does  not  occur 
in  a  number  of  other  diseases  im]>ortant  in  differential  diagnosis,  but  in 
which,  on  the  contrary,  a  more  or  less  niarke<l  leukocytosis  is  the  rule 
(p.  172).  Also,  the  relative  increase  which  occurs  in  the  large  mononu- 
clear forms  is  occasionally  of  diagnostic  aid. 

^^  lien  all  the  symptoms  previously  considered,  especially  the  charac- 
teristic course  of  the  fever-<'urve  and  the  jiiilse-cnrve,  the  [HH'nliar  stools, 
the  enlargement  of  the  spleen,  rose<ila',  and  bronchitis,  c(H'.\ist,  or  even 
if  only  some  of  these  develop  eoincidentlv,  the  diagnosis  is  generally 
easy  and  certain.     If,  however,  only  one  of  these  svm|)tjims  Ik?  present, 


•'^P. 


T!)ii^ 


:y 


^,.::_mm 


406 


rypii'iii)  iFvr.n. 


i*.:^-  :•■ 


iinil  iIk'H  111  :m  imrli;ir\rlcM-iii-  iiiiiiiiur.  tlir  i  -tnhli-liiiiciit  of  tln'  ilintr- 
iKi-is  will  trciK  rallv  rci|uii'r  a  lciii;.'(r  iiiriml  dt'  (ili-crvaiimi,  and,  alinvc 
all.  will  ciciiiaiiil  r('|icatfil,  lliiirniii.'-li  cxaiiiiiialinn.-  (lircctcd  tn  llir  cxclii- 
!-iiiii  111'  iitjiir  I'nriii-  111'  ilixa--  in  nut  a  tiu-  caso  in  whicli  ilic 
cardinal  >vniiit(ini-  nf  ly|iliiiid  lisir  do  nut  a|iiMar  nr  arc  indclinilc, 
careful  cuiMjirclirn-ivc  invotipitiim  iiki\'  |irii\idc  ilir  ha-i-  I'ur  a  mni- 
parativcly  (crtain  diaL'nii.~is  liy  cMlu-inii. 

Nut  ranlv  in  oases  nt'  dli-eure  <liaL:nii>i>  some  suddni  m  eiirrenee 
tears   awav  the  veil    and    n^nders      lear   the   exi-teiiei-  uf  ty|ihc.id  t'ever. 

AiiMiiii:  sueh  conditions  ..re,  e<|>e<Mally.  intestinal    hemorrhage, 

which  occurs  at  a  certain  ]ii  ri  cl  of  the  disease,  perforative  perito- 
nitis, and  coinliinalioiis  cf  jioth.  Epistaxis  may  also  at  times  be 
considered  nidicati\  •  of  e.xi-tinjr  tyjthoid  fever,  at  least,  it  i<  far  les.s 
likely  to  dcciir  in  .•oniieetion  with  mimher  of  ther  infections  I'.i-eases, 
which  are,  es|i(>cially  in  the  initial  stajre,  to  he  taken  into  con-idcnition 
from  the  ditfcrcntial  diaL'iiosti  stand]ioint.  it  shmdd.  however,  he  home 
in  mind  that  it  is  likewise  <jiiite  frcinient  in  cases  of  miliary  ttihercnlusis 
and  nieiiingitic  conditions. 

Nervous  impairment  of  hearing,  occurring'  at  the  height  of 
the  fever,  and  inflammation  of  the  middle  ear,  devclnping 
wliat  later,  if  with  certainty  |ireceded  only  hy  catarrhal  or  slij^ht  c 
affections  of  the  pharynx,  are  of  value  from  a  diajiiiostic  st;iiid|.oiiit. 
Conversely,  a  niimhcr  of  individual  symptoms  are  more  or  les.s  opposwi 
to  the  ])resence  of  tvphoid  fever.  Aliionj;  these  COryza  ai.d  con- 
junctivitis especially  may  he  named,  and  jaundice,  which,  in  spite 
of  the  t'recpiont  anatomic  involvt'inent  of  the  larjrer  hiliary  j)as>ajre.s, 
develops  with  extreme  rarity,  it  is  noteworthy,  further,  that  the 
occurrcnoc  of  profuse  or  persistent  sweating  at  the  hei<,dit  of 
the  fever  is  stroiifrly   oppose<l  t<i  the  existence  of  typhoid   fever. 

Xot  less  than  the  ahsenee  of  chanicteristic  individual  .symptoms, 
the  variahilitv  in  the  conrse  of  tyjihoid  fever  may  <,nve  rise  to  diflicully 
in  diajrtiosis,  and.  the  more  so,  natui-ally,  the  le>s  clear  the  history  and 
tlie  shorter  tlie  period  of  observation.  Thus,  the  tbrtnnately  rare,  rap- 
idly fatal,  fulminant  or  hyperpyretii'  eases,  especially  if  the  history  is 
not  silirirestive  of  tvphoid  fever,  and  if,  with  exee])tion  of  I'lilarjremcnt 
of  the  sjileen,  no  strikinir  symptom  has  developed,  readily  fail  of 
recojinition  duriii<jf  lii'c.  In  the  true  hyper]iyretic  ca--cs  opecial  difficulty 
is  at  times  creat'Hl  bv  the  mode  of  oii-et— with  a  chill — an<l  tlieahrn]tt, 
not  steii-like,  ascent  ot'the  teinpenitiire  to  .a  level  that  is  not  at  all  ex])(H'te(l 
in  thv  course  of  tvi)hoid  fever,  and  least  duriiifj  the  first  \veek. 

Another  form  of  disease,  of  ojiposite  character  from    the  ))rn{rnostic 


Df.iayosis. 


4(17 


^tanlll)uillt,  till-  ahnrtivc  fiinn,  cxliihit-  a  re-rnililaiicc  t"  tlic  prcccdiim- 
in  MiiiK'  r(-])<'(t>,  iiaincly,  a  >iniilar  ascent  ot'tlir  icniiHTatiirc  at  a  -inirlc 
honnd,  at  tinus  at'ler  ant(<f<l(iit  cliill,  tlicn  a  -lidi-t,  lii^^lily  tdirili'  rdiir-c, 
tcrniinatinir  i"  r(<iivtTv  willi  a  I'litical  (Icclinc,  not  ranly  witlmni  the 
cl(>V('lii[iniinl  <ii'  ru-cdla-,  intolinal  Min]itiiins,  or  even  a|i|)ncialilc 
(■nlai'i^i'niiiil  >>{'  ilic  >|il(.'fn.  S.inc  ot'  ilic  <'a-c>  nf  tlii-  cliaractcr  ai'c 
<-iin-iilcr(il  a-  iii-tani'i'-  ol'  central  |ineinniMiia,  or  even  nt'  e|ilierneni, 
nnle~>  llie  |Mcsalence 'it'  an  epiiliinie  <>t'  ty|ilii  nl  t'e\er  nr  tlie  siiniilta- 
nniMs  (iceuri'en<'e  nfdtlier  ca-e-  uliieli  are  well-niai'kitl  lead-  in  tlie  liLrlu 
direetidn.  1  lial  al-n  llie  i-eniaininj^  aty|)ic'.d  varielie-,  the  true  mild 
and  n\ilile-t  ea-e-  (it'  tv|)li()id  lever,  may  lie  a  .-<inrce  ot'  jjjreat  ditlieidty 
will  be  ohvions  t'l-om  ilic  |ire\ions  description  ot'  llieir  coiir-e.  Not  Icr-s 
ohsenrc  mav  the  |)rotracti'd,  otluTwi-e  milil  ea-e-  jirove,  t-|>eciallv  if 
attended   with   remittent,  intermittent,  or   irrejrnlar  tempcralnre-eiirves. 

Si'areelv  ri L't)i>;al)le  at  times  arc  amhulatory  and  at'chrile  eases  of 

tvplioid  fever.  I'^rror  in  diairiiosis  in  a  nninher  of  eases  in.ay  1k'  dne  to 
tiie  fact  tiiat  thoronirh  examination  was  not  made,  or  that  this  was  not 
sn^jjested  liy  reason  of  extraneons  eirenmstanees.  Iii  some  eases  roscolre 
and  etdarfrement  of  the  sjileen,  which  occni'  also  in  afebrile  eases,  and 
are  scarcely  less  common  in  andmlatorv  cases  than  in  others,  would 
otherwise  have  pointed  in  the  riixht  direction.  I  have  already  mentioniKl 
tliat  in  apparently  mild  cases,  in  which  I'le  patients  walk  to  the  physi- 
cian's office  or  to  the  hospital,  one  is  occasionally  snrprised  by  such  a 
di.scoverv. 

In  comparison  with  the  varieties  mmtioinMl,  the  well-marked  heraor- 
rliagic  cases  arc  much  less  to  be  taken  into  consideration  from  the  diag- 
nostic .standiK)int.  Fortunately  rare  in  themselves,  they  p'lierallv 
exhibit  the  I'haracteristic  symptoms  of  typhoid  fever  at  the  beginning. 
When,  however,  the  case  comes  imdcr  observatiim  shortly  before  the 
fatiil  termination,  with  an  indefinite  historv,  it  will  be  wise  to  do  no 
more  than  make  the  diagnosis  of  an  infections  disease  that  has  become 
hemorrhagic,  but  to  refer  its  explanation  to  the  prevailing  tyjH?  of 
epidemic. 

It  should  not  be  forgotten  tliat  occaslonallv  a  complication  of  typhoid 
fever  with  ulcerative  endocarditis  and  seeondary  mnltiple  emboli  of  the 
skin  may  give  rise  to  confusion  with  the  true  hemorrhagi  form;  and, 
as  has  occurr«l,  that  essential  Pc]>ticeniic  ulcerative  endocarditis,  if 
attended  with  profound  toxic  effects  upon  the  central  nervous  system, 
may  be  confounded  with  typlioid  fever. 

It  lias  already  been  seen  how  difficult  the  iliiiirnosis  mav  become  if 
certain  typhoid  disorders  of  the  viscera  or  actual  compli- 


M 


4i)H 


TV  I  ■11')/ 1 1  ii:\i:i:. 


cations  liiimiiiiiti  llir  |>ictiirc(>r  liu- (ii-ni-r  (rnu\  llic  (lutsct,  if  it  sets 
ill  (iiriitl\  wiili  ilii'  liical  iiiaiiirr-inlioii-  ulnnc,  uliilc  the  i-ciiuiiniiii; 
,s_vin|)Iiiiii»  ili-l  iiicliv  r  'it' lyplidiil  t'fvcr  lii;ikc  'licir  ;i|i|)('iii:iii(c  laliT.  We 
may  iiu'iiliuri  at  ilii~  |">iiit  the  iicplirot vpliciiil,  |)ii(iiiii(it\|)iii'i(i,  and 
])lriii'<>t\  [iliuiil,  wliiih  lia\r  alri-aily  licni  t'lillv  ilc-ci-jlxii.  l-"ar  tnnrc 
t'mniciit  than  tlic-e  \  ai'iftic-,  ami  llicrclinx'  (|iiiic  nottwuiiliN ,  is  incMinj.'-ii- 
typlinid,  whu'li  I  wa-  the  tir-t  to  ^Iiidy  caiil'iilly.  \\  lit  ii  it  is  present, 
the  dia<rnii~i>  may  lie  renilered  ail  the  mni'e  clitlienit  iiom  the  fiiet  that 
in  larjre  cities  isolated  ia~e-  ot'  lyplioid  lever  and  (•erel)io~|)iiial  nienin- 
j;itL-  almost  always  i»-,\w  >ide  hy  side.  It  is  -.dso  notewortiiv  that  in 
house  i-ndemies  of  ty]>hoid  t'ever  oe('asi()iially  nil  the  eases  set  iu  with 
meninjritie   -ymjitoms. 

The  condition  ot"  typhoid  perityphlitis  [ircvionsly  mentioned  mav 
aUo  ^'ive  rise  to  error  in  <iiaf,'no>i^  and  seriou~  iiijurv  to  the  jiatient, 
especially  when  it  develops  without  antecedent  characteristic  diarrhea, 
or  as  occurs  at  times  even  after  obstinate  eon.«ti])ation.  The  condition 
l)e<'omes  almost  beyond  the  possibility  of  diaLrno~is  when  the  appendii'itis 
develops  in  the  conrse  of  the  mildest  form  or  of  an  ambnlatorv  attack  of 
ty|)hoid  l'e\er,  an<l  the  ])atient-,  alter  the  >yin|itom,~  have  in  larj^'c  ])art 
subsided  and  are  I'ree  from  tiver,  are  a<lmittcd  into  the  hosjiital  as 
"  convalescents  fron\  a]ipendicitis."  I'nder  such  circumstances  a  relapse 
of  the  typhoid  t'ever  in  a  well-characteri/ed  I'orm  occasionally  first 
brinc-s  the  di'sired  explanation.  In  those  I'ase-  in  which  the  j)atients 
have  been  iinclcr  ob-ervation  before  the  (levelopnient  of  the  jieritvphlitis, 
the  heiirht  and  the  character  of  the  accompanvinir  fever,  as  well  as  tiie 
circum-tance  that  it  persi-ts  tiir  beyond  the  perioil  of  development  of 
the  inrtammatory  exudate,  may  lead  to  a  correct  iliairnosis. 

I'inallv,  there  may  yet  !«■  taUen  into  consideration  in  this  connection 
certain  mixed  infections  that  may  ^^rcatly  iiicrea-e  the  dirticnltv  of 
reeojinizin;,'-  ty|)hoid  i'ever  as  the  nnderlyinj;  cause  of  the  morbid  con- 
dition in  question.  The  most  im|)ortant  is  the  s('|)ticemie  variety  of 
ty])hoid  fever,  as  well  as  the  combinations  with  malaria  not  rarely 
observe<l    in    l-airoi)c,    the   trojtics,   China,    Japan,   and    North    .\meri("a. 

(ieneral  conditions,  personal  as  well  as  those  not  relatcil  to  the  indi- 
vidual, also  have  a  determiniiiL'  influence  upon  the  diajrnosis.  The  rule 
of  age  ill  this  connection  is  undoubted.  The  conditions  for  .a  correct 
dia<rno^i~  are  relatively  iiio-t  t'avorable  durinf,'  the  ])eriod  of  youth, 
inchiilinir  hH''  <hildhood.  In  earlv  childhood,  and  e-jieciallv  during 
infancy,  the  cixir^e  ot'  the  disease  mav  in  manv  resjM'cts  be  sii  nmisiial 
that  its  recoijfiiitioii  is  thereby  rendered  ditVicult.  It  must  likewise  be 
borne    in   mind   that   the   disease   frequently    pursues    an    abbreviattil, 


'  ^  \ 


Tri-: 


I  HAG. \(  ISIS. 


409 


irropiiiar,  unusually  mild  cnursc  in  ciiililivii  ;  wliilf,  (ni  the  otlicr  iiaiul, 
their  tt'iiilciicy  t<»  react  with  inii-idcniiilc  lever  to  >li;:ht,  seareelv  appre- 
eial)Ie  iiitiuences  slmulil  he  reiiu'iiihereil.  Nut  less  (iitlieuity  often 
atteii<ls  the  reeo^nitioii  ot'  typhoid  t'ever  in  advanced  lile,  in  conse- 
quence of  the  fre(juently  nnciiaracteristic  course  of  tiie  fcve.,  aiul 
PS|)ecially  on  account  of  the  almost  or  wholly  afehrile  cases.  In  i  idi- 
tion,  enlarfjotnent  of  the  spleeii  and  roscoUe  are  frequently  distinctly 
less  marked  or  entirely   wantini,'-  in  old  aj^e. 

Almost  in  the  same  way  as  in  the  aj^ed,  cases  niotlified  hy  chronic 
disease  and  constitutional  abnormalities,  as  well  as  hy  a 
vicious  mode  of  life,  niav  readily  I'aii  of  riH'Mirniiion. 

It  need  scarcely  he  pointed  out  that  isolated  cases  of  tviilioid  fever 
without  demonstrahle  C(>nncti<in  with  antecedent  or  simidtaneous  cases, 
and  especially  the  primary  cases  in  a  place,  mav  he  diffi<ult  of  diajr- 
nosis  ;  and  that,  conversely,  tiie  fact  that  tvphoid  fever  is  ]irevali'nt  in 
a  place  may  throw  light  upon  a  nuinher  of  obscure  cases  of  felirile 
disease. 

Of  j;;reat  inijxirtance  in  the  diaijnosis  naturally  arc  the  duration  of 
the  period  of  observati(jn  in  a  case  and  the  period  at  which  it  first 
comes  under  observation.  The  most  favoraiilc  staples  in  the  latter 
connection  are,  doubtless,  the  end  of  the  first  and  the  seconil  week, 
because  the  dcvelo|)ment  and  the  combination  of  the  mo.st  characteristic 
signs  occur  at  this  time.  It  is  in  the  second  week  that  the  diagnosis  i.s 
most  freciuently  made  at  first  sight.  The  diagnosis  is  generally  <juite 
diflficult  at  the  beginning  of  the  first  wwk.  At  this  tinie  one  must  be 
governe<l,  l)y  rcjison  of  almost  constant  absence  of  local  ^vmptom.s, 
almost  alone  by  the  mode  of  onset  and  the  course  of  the  fever.  It 
should  be  borne  in  mind,  however,  that  even  at  this  time  eidargement 
of  the  spleen  i<<  occasionally  demonstrable,  and  that,  particularly  during 
some  epidemics,  there  appear  not  rarely  (hiring  the  first  <lavs  of  the 
fever,  and  even  during  the  last  days  of  the  jKriod  of  incubation,  angi- 
nose  symj)toms  that  are  i)eculiar  to  typhoid  fi'ver,  and  whicli  may  cause 
the  inexperienciMl  to  confuse  the  condition  with  croup  and  diphtheria. 

Tlie  diagnos's  is  generally  easier  during  the  stage  of  deferves<'ence 
than  during  the  first  days  of  the  disease.  It  will  then  usually  be 
known  that  a  febrile  condition  has  prece<led,  or  a  poilion  thereof 
may  be  observed,  and,  besides,  there  are  likely  to  be  found  resithta 
of  roseohe,  develoi)e<l  sudaminal,  persistent  eidargement  of  the  spleen, 
bronchitis,  hypostases,  and,  finally,  the  characteristic  febrile  course  with 
the  well-known  steep  ciir\-es.  In  patients  who  come  under  obser- 
vation   in    the    first    period    after   defervescence,    persistent    subnormal 


■'\^:-^-k 


>.'«-.-E.,f  . 


4T0 


TYfiiniii  ii:vi:i:. 


■•<■.  ■ 


ttiii|iiTaliir<'  willi  nlMtivrly  ^'ri'ut  rriM|U(iiiv  ami  iii-t:il>ilitv  i.t'  tlic  iml-c 
is  iiiclic  alive  lit'  an  ariliicdtni  >cvcrr  trhrilc  (li~ra-c,  ami  in  niiMc  nl'  all 
tlicsc  is  tlii.-  symptiitn  mi  li(i|U(nt  uml  mi  l)«•r^i^ttllI  a-  in  ls|ih.ii<l  tl  \  i  r. 
Tiir  iiiipiprtaiicc  nf  the  iliatrnn>i-,  oincially  alter  the  lerinination  of  the 
actnal  ili-ease,  willi  niranl  tn  the  iliet  ami  |ieriiii.->i(i:i  tn  pi  <iiit  ut'  In  il, 
mill  (inly  he  inenliinied  at  this  plaee.  ili  liience  inav  he  niadi-  here 
ajraiu  to  the  (liaLHin-iie  ^i^rnitlc■anee  ot'  relapses.  F.very  exnerieneed 
|ihy-iiaan  will  he  ahle  to  i-eeall  ea~e~  in  which  rela|i,--( -,  h\  their  ree-iilar 
tyjiieal  euurse,  clean d  u|',  I'npni  the  cli,,i:nii.~lie  slandpoint,  [iriinarv  rehrile 
states  which  ]iiii>ued  an  irrcirnlar  eoiir-e  nr  did  not  at  all  innie  UiidiT 
immediate  ohservatinn. 

SPECIAL  DIFFERENTIAL  DIAGNOSIS. 
Ilavini;  estahlished  trnidiiiLr  principles  with  re^rard  In  individual 
syniptonis.  syinptiini-Lrniiip-,  and  pneral  inndil  ion-,  wc  tnav  now  eon- 
tiider  some  ot'  the  most  important  di-ea>es  which  ina\-  he  eontonndcd 
with  typhoid  fever.  I'ew  ot"  thcM'  arc  to  he  taken  into  consideration 
from  the  standpoint  of  ditltTential  diaL'no-is  thronj^hont  the  entire 
course  of  the  (ii-ieas(\  hut  most  of  them,  aeem-dinjr  to  their  character 
and  their  manifestations,  are  to  i.  eoii-iilcrcd  onlv  duriiii;  certain 
staL'e-. 

Acute  Miliary  Tuberculosis. — <  onfu.-ion  of  typhoid  fever  with 
acute  miliary  tuherculosis  i~  especially  frei|nenf,  and  vicf  rersa.  The 
Ix'-t  diai^nostieians  have  made  uii-itakcs  in  thi>  connection,  or  have 
failetl  to  reach  a  delinite  coiiclu>ioii  after  week>  of  ohservatinn,  imtil 
finally  the  recovery  of  the  patient  [imvcd  the  ea^'  to  be  one  of  tyjihoid 
fever,  or  po-t-mortem  examination  showed  it  to  he  one  of  niiliarv  tnhcr- 
cnlosis.  The  ])rincipal  dilllenlty  in  the  ditfcrciitial  diajrnosis  re-iile<  in 
the  liict  that  hoth  ili~eases  often  exi-t  for  a  con-iderahle  titne  without 
C'on-|iicuous  lot  d  manifotatioiis,  while  the  distnrhaiici's  in  the  general 
eomlilioii  due  to  the  action  of  toxins,  the  typhoid  state,  mav  he  e(jUallv 
developed  in  hoth.  liotli  di--eases,  after  an  eipial  dunition,  are  attended 
■with  sopor,  niutterit)'_f  delirium,  floceitation,  siihsultus  tendinuni,  and 
finally  coma,  and  are  prece<led  hy  headache,  vertifro,  lantr'ior,  and  often 
nosehleed. 

It  has  heen  said  that  the  course  of  the  temperatur(>  is  distinctive  in 
each  disease.  This  may  he  apjjlicahle  to  typical  eases  of  typhoid  lever. 
In  protracted  atypical  cases,  however,  the  temperature-curve,  espeiially 
the  markedly  remittent  or  iiilermitletit  type,  may  jrreatly  iiK'rease  the 
difficulty  of  differentiation  from  miliary  tuberculosis.  Profuse  j)er- 
sisterit  swcatinjr  durinir  the  febrile  statue,  es])eeially  with  an  intermittent 


^ 


1)I.[(,.\()SIS. 


Ill 


t»'iii|i(ratiin'-(iirvi',  i-  in  favor  ot  iiiili;ny  tiilx  r(iil(i>i- and  M^:iiii-t  tvplinid 
I'cvir.  Mure  impdrtant  than  ilic  .-talr  ot  ilic  i(  ni|iiratiirL'  mav  Im  thai 
of  ilii'  |iiil-i',  ina-ninili  as  ii~  nlaii\c  ^lownt■--,  mi  fri'cjntiitly  oli-crxol 
in  ca-r-  ..('  ivplioid  fever  in  yontlit'ul  indiviilnal-,  does  wil  oeeiir  in 
ea^es   <it'   niiliarv   tlli)ereulo-i-,   e.\e(|)t    111    llie    |ir(-enee    ot'  a  eonil  linal  ion 

wiiii  liii-iiar  nieniiiLriti-,  \\lneli  i~  readily  iceo^rnizaiile  from  other 
-virjitoin~.  .NFarknl  di<roti-Mi  ot'  the  jiiil>e  is  also  incoiujiarahly  K'.~s 
<'oiiiinoii  in  eases  of  miliarv  tMliereulo-i--. 

I'lii'  a|i|>earailee  of  the  patient  may  alone  he  of  -.olne  importalleO  to 
the  trained  oh-erver.  In  tiie  ide-enee  of  miliary  tnliireido-i~  a  |Meliliar 
sjijrht,  dilVnse  lividity  exists  at  the  heiirht  of  the  di~ea-e,  which,  in  eom- 
hiiiation  «illi  the  !_'eMeral  pallor,  ^.dvi-  ri-i-  to  a  eharaeteri-tie  ajiptar- 
anee,  e-peei,dlv  ot'  the  face  and  th(;  e\tremitie-.  '!"he  state  of  the  spleen 
al-o  i-  notewortliv  ;  it~  enlarL,'ement.  lieLriniiiiiLr  toward  the  end  of  the 
lir-t  Week  ot'the  di<ea-e  and  iiroirre-^-iiitr  from  tin-  time  to  the  end  of  the 
>eeond  week,  is  in  favor  <it'  typhoid  fever  ;  while  eiilarfiemelit  of  the  spleeu 
is  mneli  lo-i  constant  in  the  pre-ence  of  miliarv  tnhereiilosis,  and  is  even 
not  rarely  permanently  ah-ent.  That  small  hyperetnic  papidar  ^pots, 
ill  Lreneral  not  distinirnishalile  from  roseo|.i\  may  he  |iresent  al^o  in 
ea-es  ot'  miliary  tuhereidosis,  thoiie-li  rarely  and  in  small  nntiiher,  has 
been  previon-!v  inentione<l.  A  prnfnsion  of  roseola'  of  tvpieal  develop- 
ment and  ili-trihntion  is,  however,  distinctive  of  typhoid  fever. 

I  am  niuilile  to  :i<rree  inieonditionally  with  the  opinion  that  the 
ah.-ence  or  the  ])resenee  of  meteorisni  is  distinctive.  It  is  tnii',  flatton- 
injr  i>r  rotraetion  of  the  alxlomcn  is  more  frei|netit  in  eases  ot'  miliarv 
tuhereidosis,  es|)eeially  if  the  eereliral  menihranes  arc  alni  iiivolviil  ; 
but,  as  has  .ilready  Ikhmi  meiitioniKl,  typhoid  fever  also  is  i|i:ite  eomiiionlv 
tniatteiided  with  noteworthy  meteorism  either  temponirilv  or  perma- 
nently. If  it  he  considered,  in  addition,  that  ^evere  eases  of  miliarv 
tuberculosis  may  also,  precisely  like  severe  cases  of  typhoid  fever,  be 
att(>ii(led  with  marked  distention  of  the  abdomen,  the  dianno^tie  value 
of  this  -ymptoin  is  fnither  iliminished. 

\\'itli  reji^ird  to  the  diasrnostic  si<rnitieance  of  diarrhea,  it  should  not 
be  overjooke'l  that  thin  stools  may  oeeiir  also  if  ea<es  of  miliar^'  tiiber- 
eiilosis,  especially  when  old  intestinal  uleenition  is  present  ;  tliev  may 
even  be  of  a  yellow  color  when  ''c  diet  is  predominantly  licpiid  and  of 
milk.  'onsti|)ation  or  refiularity  in  the  action  of  the  bowels  is  not 
distinetive  one  way  or  the  other;  while  intestinal  heniorrhn<re  iK'cnrs 
almost  solely   in-  cases  of  ty])hoid   fever. 

The  symptoms  refer.ible  to  the  Imiirs  may  also  inerea.sc  rather  than 
diminish  the  ditlieiilty  in  ditrerentiatin}^  the  twii  diseases,  jiarticularly  at 


1 


■1.  ; 


^ 


I' 


TV  nil  nil  n:\i:i: 

the  lMj;iiiiiiii^'.  lloili  art'  Mttiiiilnl  with  a  i|r\.  -Ii..it  cdU).'!!,  with  scniitv, 
iiiaini>(i.|ii(".illy  wliollv  uiiihararicri-lic  cxiiiildratinii,  ami  in  wliich, 
even  ill  ia-c~  of  iiiiliarv  tiilit  niilo-i^,  tiihcnli-lpacilli  an  rmiinl  milv 
rxctpiiniiallx ,  and  ilun  arc  ■Iciivcd  I'nmi  older  uli  (niti\c  foci.  ( )n 
pliy-ical  cxaiiiiiiatiori,  with  a  Hernial  |h  r(  ii>.-iiiii-iiotf,  drv  rale.-,  ~iliilaiit 
and  '.inoi-oiK,  arc  p'ticmlly  itrocnt  in  Loth  di-ca-o.  if.  liowcvrr,  an 
c-lHcially  d.n~c,  tVi-h  <iii|.lion  of  tnlwivl.-  in  ihi-  Inn^r-  o  ciir,  in  a 
■a-f  of  miliary  inhcn'iiloM-,  hi^'hly  charartiri.-tii-  niaiiitr-tatioii-  may 
n-iiit,  namely,  Mil.jeetive  dy.-pnea,  with  far  more  marked  inerea.-e  in 
re-|)iratory  freijiieiiey  than  oeenr-  in  ea-es  ot'  ivphoid  Uver  witli  ;i 
.-iniilar  ranp'  ot'  teni|"nitiire,  aiMJ,  at  the  -ame  time,  aente  pulmonary 
emphy-ema,  an  e-pi  cially  dn  i-i\  e  olijiiiive  -\i:it,  uhieh  lia-  iiitiierto 
reeeiveil  tar  too  little  atteiiiion,  and  w  liieli  has  rendered  me  exrelieiit 
.-.erviee  in  many  ea-e-.  '1  his  |iiilmonary  emphvsi'iiia  never  oeeiirs,  in 
my  e.\],erienee,  a-  the  i-eMilt  of  tyjihoid  liroiieliitis,  while  it  i>  an  almost 
natural,  r.adily  expliealile  rt-nit  of  the  direct  or  indirect  <«■<  In-ion 
(it  the  hroiK  hioles  hy  a  imifoiin,  dense,  and  recent  ern|ition  of  tiiiierties. 
I  he  dillirential  coimt  of  tiie  lenkoeyto  inav  lie  of  eon.-idendile  value 
in  ditlerciitiatinL'  the^e  two  conditions,  in  liotli  of  which  there  is  a 
decrea>e  in  the  ahsuliite  mimhcr.  ]5iit,  while  in  typhoid  fevtr  there  i> 
iisnally  a  relative   increa>e   in   the  larfre   inononiielears,  in   .acute  tniliarv 

tlllierrulo-i-    llii~    does    not    oe<'lir. 

<  )ne  examination,  finally,  -honld  never  1 niiltc<l  in  donhtfnl  ctises, 

namely,  that  of  tlie  cye^ri'ound  tor  ttil)crclcs  of  the  choroid.  It  is  true, 
thi-  deei-i\e  condition  o<rnr-,  accordinj.''  to  manv  writer-  and  mv  own 
experiiiice,  only  in  the  minority  of  ca^e^,  and  it-  deteition  is  it'ten 
rendert^d  more  dillicult  from  the  fact  that  the  nodules  devcloi)  with  a 
fcrtain   dcL't'ec  of  preference  at    the   |)eri|ihiTy  of  the  cvcpround. 

|-"iirther,  it  should  always  he  iMirne  in  iinnd  that  ivphoid  fe\  ir  niav 
!)(>  complie.ated  liy  miliary  tiihenMilo-i-.  It  is  true  that  this  ^^cncrallv 
occurs  diirint,'  the  later  statrcs  of  the  disease,  and  even  diirint:  <'onva- 
le-<'cnce.  In  the  latter  event,  even  careful  ohservers,  espcciallv  at  the 
Ixtriuiiiiiir,  will  not  always  he  -eeiire  a^rainst  the  possiliilitv  of  niis- 
takinir  this   for  a   n  lapse. 

Meningitis. — When  acute  mili.iry  tnhcrciilosis  i>  attended  with 
basilar  meningitis,  the  diairnosi-  i-  therdiv  rendert'd  rather  easier 
than  nion  difficult  ;  the  reasons  for  this  need  not  he  {riven  in  <letail 
here.  From  the  KcLrinninir,  under  such  circumstaix'es,  the  tinilstiallv 
severe  headache,  the  ohstinate  vomitinjr.  espcciallv  after  the  iiiLrestion 
of  fiM)d,  are  far  more  indicative  of  impending  meningitis  than  of  tvj)hoid 
fever. 


i>l.\i;.\()sis. 


41.{ 


It  ii(<<l  sciirnlv  l(f  n  |M;it<il  tliat  in  a  duulitl'iil  ia>f  liiinl>ar  |iim<tiiii' 
often  |ir()Vi'>  i>l'  tin-  ).'rtai<'~t  viiIik  . 

I'liat  simple  purulent  meningitis,  nri^'inatinR  Irum  (li-«:i-.> 
<.r   the   iKisf  iir   I'l'    the   mi. Idle   <ar,  iiiav    Mow  and   af:ain   t;ivi'   ri^'   l.i 

d,nil)t  anil  I'n.-i.m  nc*"!  "nly  1h'  Urirlly  tnintii>ni-<l.       I'lic  runsiicnticnis 

physician  will,  apart  IrDin  thi-^,  make  an  ixaiiiination  i>{'  tlu;  tars  and 
ot'  the  iiasopliarvnx  in  the  ease  nf  every  Hhrile,  s(i|K>r>i.se  patient,  and 
in  a  HU.si)iei(iiis  ea.-M'   linnhar   puiutnre  -honid   lie   |h  rfiirnie<l. 

With  renani  t(.  epidemic  cerebrospinal  meningritis,  and  the 
possiliility  nf  eunrdiindini,'  it  with  typhoid  fe\er,  I  may  refer  to  a  pru- 
viiiiis  chapter  (pp.  'l>i'.^ -'2~  I). 

Cryptogenic  Septicemia. —  i'he  ditlereiitiatinn  ,.f  cryptofrenie 
septicemia  ln>in  tvphoid  lever  may  under  ^(lIne  eircnnistaiK'es  he  (jnitc 
difficult.  The  (piite  usual  development  of  a  typhoid  state,  the  f'ehriUs 
amrse,  whicii,  pri-cisely  as  in  a  ca.se  of  typhoid  fever,  may  e.xliihii  the 
curve  of  a  omtinueil  or  a  remittent  fever,  ami  the  rarely  ah-^iit  enlarge- 
ment of  the  .si)loi'n,  are  particularly  confusiiif^  in  this  eoiuuvlion. 
Ditl'use  bronchitis  als..,  (piito  similar  to  that  of  typhoid  fever,  is  not 
rare.  Diarrhea  is  almost  a.s  inconstant  as  iu  ca.ses  of  typhoid  fever. 
Frecpiently  there  is  slijjlit,  at  times  even  marke<l,  jaundice,  which  will 
then  be  strongly  in<lic:itive  of  sei>ticemia.  In  thes.;  <'a.se.s  bloo*i-c'ulturua 
are  often  of  decisive  diagnostic  value. 

Other  Septic  Processes. — An  answer  to  the  question  whether 
puerperal  septicemia  or  typhoid  fever  is  present  may  under  some 
circumstJinces  be  attendt^l  with  greater  difficulty  than  would  Ix-  l)elieve<l. 
On  one  hand,  esjRHially  when  the  history  is  indetinite,  severe  puerjH-ral 
septicemia  of  typhoid  course  may  \>o  mistaken  for  actual  typhoid 
fever;  and,  on  the  other  hand,  it  should  always  be  iKirne  in  mind  that 
pregnant  women  attacked  with  typhoid  fever  quite  generally  suffer  fnim 
abortion  and  premature  labor.  Und  r  .such  circumstances  it  has  re- 
piitetlly  hapj)ene<l  that  the  cont-.-.uition  of  the  typhoid  disease  was 
looked  upon  as  septicemia  in  coni.ection  with  supj^o.sed  primary  prema- 
ture labor.  I  have  {)ersonally  observixl  ca.so.s  in  which  the  history  and 
the  clinical  conditions  were  so  ob.scure  that  only  the  appearance  of  dis- 
tinct roseolae,  or  even  seruni-diagnosis,  clcartKl  up  the  condition. 

Ulcerative  endocarditis,  which  has  b<>en  mentionwl  repeatedly, 
and  is  to  be  considere<l  among  the  .«eptic  processes,  is  also  generally 
attende<l  with  symptoms  of  the  typhoid  state,  and  not  at  all  rarely  with 
recent  enlargement  of  the  sjileen.  Nevcrtlieless,  the  emlxilic  lesions  of 
the  skin  that  occur  will  not  readily  l)e  confounde<l  with  the  typhoid 
roseolae.    esneciallv    as  other   emboli,    recosrnizable    without    difficulty, 


'^:    •     1 


II!!!' 


II  i 


Tvrtinih  I  i:\i:n. 


),'iri.  rally  uvciir  in  tijc  nliii:i,  llic  liniiii,  iho  kiiliii\.,  and  tiii'  Imii.'S. 
Naturally,  the  aciilc  d.  \  i  iMpin.  rit  nl'  a  laniiac  atrcrlinri,  wilh  ilc  Kilitv, 
irrc;.'iliai'ily,  and  nniriuiit-,  will  in  t  readily  Ik'  ovcrJiMikrd.  '  Tlic  mi-ct 
may  Dociir  will  n   lln    luaii  ua-    |iri\  iiiu~l  v  inlail,  ur — and   this  rcndiTi 

I'l ^rniti'iii  I'!    till' I'lridilin-i  nioiT  ditliiiill  — il   niav  rnni|iliralr    iiriviniis 

valvular  Ir^imi-.  'i'lii'  diairnn-i-  will  Im-  l-nililati-d  if  it  \»-  JMirnr  in 
iiiiud  ihal  cndiMardilis  (  not  -.pliri  i>  .  Ainimly  rare  a>  a  cuiniilicaliDn 
"t  l\|ili(iid  |r\rr.  and  that  inyiM'anlili-  al-o  i-  li\  no  inian*  rrci|iii  iit  ; 
and  lliat  liuth  iM-nir,  il'  at  all,  'jiin  rall\   at  tlii'  liii;:lil  nr  toward  llir  end 

■  it  -ivcrc  ia.-( il  a  |Mrio(l,  tlnritlirc.  wlicn  it  lias  jrcniTallv  Im  ii  jmssi- 

lili'  to  niakr  ilir  iliaL'iio-i^  ot'  tv|ilioid  I'rvi  r  willi  cirtainls. 

In   youtliiiil  ]i'r  on-   infectious  osteomyelitis — ii(-i<,Miaicd  iiv 

Fnii'li  inv(-.ti;,'aloi-  (( 'lia-~aiLrnar)  I -pi  riallv  a^  "  Ivpln'  i'pi|iliv>airc  " 
— i-  not  ninly  llir  caii-i'  tor  i-rror  in  dia!.'iio>i,.  In  ^nl■ll  pcrsmis,  with 
an  oli^riui'  |.  lirilr,  iy|)hoid   ^yinpioni-<oni|ilr\,  di  |H'nd''ti(c  -iiould  iicviT 

'"■  Jilarid  n| the  all-cm  r  ot' roniplaini<  rttirrrd  to  tlir  cxtrrniitic-,  hut 

til'-'-  should  alw.iys  he  fxaniiiicd  carrt'iillv  top  edema,  livid  ridne»,  and 
eirciimsiTihed  tendcrtu-s  e-peiially  tiie  epiphv-eal  regimis  ot  tin  long 
mednllated   Imiies. 

Intoxications. — I>oulitle-s,  intoxiration  fmin  the  inircstion  of 
diToin]io-id  orpiiiie  >ul>-lanee-  (  nie  at,  tisli,  mii-,-e|- i  and  fluids  (water, 
milk,  etr.j  contaminated  l>y  the  prodiicls  of  pnirel'action  al-o  ^'ives 
riM'  to  acute  intestinal  di-onjers  with  -'tvphoid"  svmptoms.  Thi> 
inhalation  of  putri<l  umx's  also  appears  to  he  capahle  of  j^iviiij,'  rise  to 
diarrhea,  with  cnlarLrenicnt  of  tlic  spleen,  lever,  and  stupor,  as  is  shown 
hy  many  re|iori-  in  the  literature,  amoni;  \\hich  are  the  well-known 
iiislanees  in  I-JiLrland  |ireviou.-ly  tuentioneii  (p.  .  ■  ,,  wiiieh  at  the  tiino 
(if  their  ]iulilication  were  exploited  as  supporting  the  pytiiogenie  theory 
of  typhoid  t'cx'er  (|i.  '2<i). 

Malaria. — Maknia  generally  will  give  ri-e  todifHcultv  in  diairnosis 
only  in  those  ri  gions  in  which  tiie  ca>es  present  remittent  or  eoniinued 
li'vcr.  Krror  may  under  such  circuiMstaiice-  he  made  in  I'ither  direc- 
tion, ina-muih  a-,  on  tin-  one  hand,  malarial  proce->es  niav  lie  mi-taken 
I'lP  typhoid  ;  and,  on  the  other  hand,  t'lilminant  tv|)hoiil  fe\er  mav  he 
nii-taken  for  iiernicioii-  malaria.  That  rare  lases  of  amhnlatoiv  tvphoid 
fever  with  intermittent  fever  and  chills  may  nndcr  certain  conditions 
simulate  malaria  has  already  luen  mentioned.  Ivxamination  of  the 
lilooil  for  malarial  para-iie-  n-ually  c|,>:\r-  up  the  diagnosis  without 
dillicultv    in    these   ea-e-. 

Influenza. — The  confusion  of  influenza  and  tvphoid  fever  is  ocea- 
-iouallv  nardonahle.      The  hiirh  fever,  the  nrostration.  and  tiie  stiiiior  of 


/'/  {i;\<is[s 


II 


llic  iKiticiit-,  Mii'l  nilicr  -rvcrr  lurviiiis  ;:i'ii(  r:il  iiiaiiiti>t;itiniis,  may  ron- 

iriliiiti'   III   ilii-  1  ml.      It    is    im|Mirtaiit    in   tlii-   •■ liiun    tn   nlitaiii    a 

liiMiirv  111'  tile  III  ^iiiliill;;  111"  llic  iliscaM'.  In  i-a.-ts  ul'  ilillllclizji  lire 
initial  "•iirvza,  wiili  \\lii<li  arc  sim.ii  asMniattil  Ian  ii;.'iitraiii<itis  ami 
li- iiiiliiti^,  will  ii'it  iiMiliiv  I"'  ii\<  rluiikril.  Ill  rax'^  lit'  ty|ili<iiil  t'i\ir 
corv/a  i-,  a>  lias  Imcii  luiiiliuiicil,  an  cviriinciy  rirc  cunilitinn,  ami 
atVr<tii>n-<  lit"  tl  •  larviix,  as  \m11  a-  lir.nnliial  <atarrli,  ^'iiicrally  do  imt 
make  tlicir  a|)|«'araii(c  littniT  tlw  svcunil  wiik,  nr  fViii  lattr.  Hoid.s, 
(■nlari,^!  niciit  ct'ilir  spleen  is  n.-iialiy  wanting  ni  eases  ut' intliien/a,  u  liiie 

tlie  m-eiila,  or  an   ■       mllielii    resellllililli:  II,    i-  lie\,  r  uli-erveil. 

The  Acute  Exanthemata.— Aninnu'  ilie  ili-ease-  that  |>iai  tically 
never  ^'ive  ri-e  to  ilillieuliy   in    ilie  ilill'i  reiitiai  (liiu'iin.-is  at  tlie  iieij^lit 

(if  tlieir  (leveli)|illlelll,  lilll  iln  -' i  all  llle  nmre  tVei|Uelitly  ill  liie  i;iitial 
staj^e,  are  the  aeiite  I  \anllieinala.  Scarlet  lever  anil  variola  |iarliciilarly, 
and  also  mea-lt>  diiiinu'  llie  |iriiiiaiy  Icmi-,  may  i)e  re-|iiinsil)lc  I'nr 
such  criiir  in   miiiiil''   iiciauii-   individual-.      .Vpart  rnun    the  kiiii\vled;;e 

of  the    |irevaleiiee  nf  the   one   nr   tl tiler   of  the  ili>ea.-es    in    (plest iiili, 

the  local  initial  -yniptmns  that  ,ire  mmhi  a<lded  to  the  ilUlelined  p-iienil 
fehrile   stale  will  -"oii    -erve   as   a    ^'nide  to  liie  carefid  oli-erver.      Vi'Uh 

rej,'ard  to  measles,  importance   is  to  he  atlaeiied   ti njimetiviti.s  with 

eorv/.a  and  catarrh  of  tlie  np|><"r  air-i)a-saL'es,  and  with  re^r-if'  to  scarlet 
fever,  to  the  di-tinetive  aiii^'ina  ;  while  in  cases  nf  small-jMix,  the  cliar- 
acleri-tie  sacral  pain,  a-  well  as  the  initial  exanthemata,  particularly 
the  scarlatiniform,  in  the  trianirlcs  of  the  thitrhs  and  the  upper  arms, 
and  the  ap|>earaiiec  of  the  variolous  etlloreseeiiee  ujM)ii  the  pharynfjeal 
nuicoiis  niemhrane  iminediatcly  afterward,  at  limes  almost  siinultaiic- 
ouslv,  will  lead  in  liie  riirht  direction.  At  a  later  |)eriod  varioloid,  with 
a  scantv  tr'iMtion  accident. d'v  nliiicil  to  the  trunk,  may  at  most  he  a 
.Source  of  doubt.  If  it  he  liorne  in  mind,  liowcvir,  that  the  variolous 
eruption  almn-t  ituexce|itionally  appears  lirst  upon  the  t'ace  also  in  cases 
of  varioloid,  that  consianiK  with  its  ap]iearance,  even  in  the  severest 
ease:*,  decline  of  tein[)enitiire  takes  place,  one  will  .seldom  he  seriously 
einharrasscd. 

Typhus  Fever. — The  ditferential  diairnosis  may  hi'  far  more  <llfti- 
eult  with  ri'irard.  to  tv|)liu-  liver.  Thi-  is  exiiihiied  iiistorically  in  the 
fact  that  the  two  di-eases  were  not  projicrly  di-tiiiiruished  from  each 
other  up  to  the  midille  of  the  nineteenth  century.  Kven  at  the  present 
dav  the  ciiuditioMs  are  not  verv  .simple  in  cnuntries  and  at  times  in  which 
both  diseases  are  constantly  prevalent  side  i)y  side,  and  it  is  precisely 
imder  •iieh  circumstances  that  early  and  accurate  dia^'no>i>  is  of  impor- 
t.Tnee  with  reiranl  to  the  interests  of  the  comiiuinilv.       If  a    decision    bo 


^'f 


m 


ii*i 


rvriiDih  i-i:vi:i:. 


m 


m\ 


(Ic.-irrd  ill  tlic  fir-t  !t\'.  i\:w<  >A'  \\v  '\\~v\\-<\  it  \\\:\y  !"■  iilmo-t  jin;"'— ililo 
if.  ill  ai|ilili'>ii  to  till'  lilirilc  "  tv|iliiii(l  "'  -tat,',  tlic  ili-tiiirti\  c  cutaiicniis 
niMiiit'otatiiiiis  liM\  (■  iiiit  yit  ilcv  iln|>((l.  It  -IkiuIiI,  lu-iilc^,  always  be 
ii(,t,.i| — what  llic  iiu\|M'rii'iii'i'(l  I'ladily  dVirlonk — tliat  even  in  (luitc 
M'vcrc  caso  111'  tv|iliii-  t'cvcr  ilic  cliAildpnurit  nt"  tin-  a-Miriatcd  cniiitiitn 
niav  III'  cxticiiiiK  iiupi  rf'i'ci  ni-  alinii>t  (iimiilctcly  aliM'nt.  In  the 
iirc-c'iicf  of  a  iiiaiki'ij  ex  iiilliciii  in  i-iiniici'tiipn  witli  Imtli  tli.-t'a.-cs,  tlic 
(iitl'cfcntialiiiii  i-  la-x  tiir  an  (■\|i('ii"ni  ril  iili-(  rvi  r.  The  typlmid  m,-  'nla 
is  almii-t  triMii  the  iifi;iiiniiii.''  -liirlitly  cli'vaicii.  |iaiiiilai',  ami,  tlirdn^'iidiit 
its  riitirc  (Inratidii,  piii'dy  hypcrcinic,  (•<pn>lantiy  liiculur,  ami  siiai|ily 
(Iflincil.  (  )n  the  utlirr  hand,  the  >]>i>ts  of  typliu-  t'cvcr  arc  l('>s  sliar|ily 
limited  and  arc  ill  ditliicd  :  at  tif-t  jialc,  tlir  iiiajurity  mhiii  liccotiif  htin- 
(irrha^'ii-,  ~ii  that  tliry  arc  then  ,-iinplc.  imt  elevated,  s|>(iis  nt'  IVoni  a 
(hiskv.  euppcry  ndncs-.  only  in  part  disa|ipcarinir  'Hi  pressure,  tn  a 
ilark  livid  cnlur.  which  then  distinctly  cxhihit  their  petechial  character. 

The  diaLrnii-i-  i-  t'acililatcd  hy  the  tact  that  the  spots  n\'  tyiihus 
fever  appear  earlier  than  the  typlmid  niseula — lictween  the  second  and, 
at  the  latest,  the  lit'th  ilay  of  the  disease — and  iliey  ra]iidly  attain  their 
ilctiiiitivc  dcvelopnient  -iiiLdy  and  collcctiv. 'y  .-it  a  sinirle  stroke,  inva- 
rialilv  without  recrndocence-,  within  from  forty-ciLdit  tu  scvciity-two 
hour.-.  The  <litl'eren<'c-  in  the  distrilmtion  ot  the  eruptions  over  tho 
surihce  of  the  liodv  in  lioth  di.-case-  arc  al>o  notcwurthy.  A\"liile  in 
cases  of  tvphus  ti'vcr  the  trunk  and  the  extremities  arc  (piitc  uniformly 
covered,  in  cases  of  t\  phoid  lever  otdv  the  |iarts  of  the  extremities  adja- 
cent to  the  trunk  are  iiiMilved,  and  the  remaiiiinL''  Jiortioiis  ;ire  involved 
in  lesser  decree  the  further  removed  tiiey  are  t'roni  the  trunk.  In  cases 
of  tv])hiis  fever,  when  the  exantluii'  is  devclo|>ed  to  any  cou.-ideralilc 
dofrroe.  espcM'iallvihc  forearms  and  tlu>  Icirs  are  prcferalily  iiivoU  cd,  and 
als<i  the  dorsum  of  the  hand-  and  the  icet,  -o  that  I  ailvisc  carefid 
inspection  of  these  parts  when  there  i-  susjiicion  as  t- the  presence  of 
this  disea-c.  With  rcjr;ird  to  the  face,  there  is  a  certain  dcfrrec  of  ajrrco- 
nieiit  hetwccn  the  two  di-case-,  in  ^o  far  a-  in  the  vast  majority  of  ca-cs 
ot'  tvphus    fe>-er  this  al-o    i-   likely  to    remain   free  from    the   exanthem. 

On  tl ther  hand,  the    IIh'c  in  the   l.itfer  di-ea.-c   exhihits  a  niiinlier  of 

other  distinctive  t'eature-.  Kveii  from  the  licirinnintr  it  is  diffusely  red 
and  turLnd,  the  eoniiinctiva'  are  vividly  inji'ctc<l,  snl)>e<pieiitly  <ilteii 
ccchvmotie,  while,  in  addition,  the  face  has  a  wild  and  st.irtlcd  expres- 
sion, which  i-  in  marked  contrast  to  the  iiiditVcrent,  dull  exprcs>ioii  of 
the   tvphoid    patient. 

Not  Ic-s  important  than  oh-crvation  of  the  -kin  in  the  diifercntia- 
tion  ot'  the   two  di.-ea.-c-  is  the  course  of  the   i'cvcr.      In  ccnitrast  with 


lUAcyosis. 


417 


the  laniiliiir  -itp-likc  a-i'dit  in  cm-i'^  m|'  tv  plii'iil  t''/\w  r.  the  tciniicntiiro 
ill  ca-c-  I.I'  iy|iliii-  t'cvcr  LTfiirrallv,  al't'^r  .iiic  or  ranlv  -cvcral  cliill,--, 
ri.-os  rajiiilly  Id  its  li(i),'lit  wiili  -liiilil  inii  ri-iiptidii,  sn  tliat  witliiii  tVniii 
twoiily-l'diir  I.I  liiiriy-si\  limii^  a  k'\i'l  ot"  tVoiii  In.-")-  tn  41°  C.  is 
rca<-licil — a  tar  liii^hrf  lr\cl  tliaii  in  ca^c-  d'  tvjiliuid  lever  at  tliis  tinu', 
iir  even  In  I'a-e-  nt'  imt  unduly  exee-,-ive  .severity,  tlirmii^diont  tlie  entire 
l:i>tii;imn.      The    I'lirtlier    eoutve    nl'   tlie    t'evi'r    al-ii    exhibits    ini|Mirtaiit 

(litlereiiees  tiiat  <'aiiiint  li ln^i(lel•e(l  Ihlly  at  thi-  |i(iiiit.      Its  tutal  diira- 

timi  (liie.~  nut  exeeeil  frmn  t'on.'teeii  tusesenteen  (lavs  even  in  the  innst 
severe  eases  ut'  ty|)lMis  t'e\  er.  It  trcnerally  terminates  with  a  eritieal  ur 
a  rapid,  -tep-like  deeline.  With  the  aiiru|)t  unset  anil  the  rapid  ascent 
(it  the  tever  tn  a  e(.n~idei-aliie  lieiLrht  ci .rre-piinds,  in  cases  of  tvphiis 
fever,  alsii  the  tar  earlier  appearance  (if  the  severe  ^'iieral  iiiaiiifesta- 
tiiitis,  with  the  unii-ual  pni-tratinn  that  edinpels  the  patient  to  take  to 
his  hed  as  early  as  the  tir~t  or  tlie  -ecdiid  'law  The  diher  jirnt'onnd  dis- 
Iiirhaiici"  referalile  to  the  iierxnii-  -v-tem  alsn  appear  much  earlier  than 
ill  cases  ut'  typhoid  fever.  As  early  as  the  tirst  days  thrioiis  delirium 
oftoji  (Kriirs ;  and  t'rotii  the  hej^imiitig  of  the  siH-oiid  week,  protliiind 
coma. 

'I'he  j)iil~c  in  all  cases  of  typhus  fever,  without  reference  to  aire  and 
sex,  is  exceedingly  t're(iucnl  tVdm  the  licLriiminir.  in  Wdineii  and  children 
it  may  he  1  L'n  and  more  diivinu''  even  the  tirst  da\s  ;  also,  in  prcvioiislv 
heilthy  ydinii:  men  a  tVii|Ucncy  of  pulse  is  sometimes  eneonntored  at 
the  l)ei,dnnin!.'.  'iich  as  i-  rarely  oli-erved  at  the  heifrht  of  the  disease  in 
cases  of  ty|)hdid  t'evcr.  I^ularirement  of  the  spleen  is  far  less  constant 
ill  cases  of  ty])lius  than  iu  tho~e  df  typlmid  iever.  When  it  occurs,  it 
develops  eat  tier  and  it  subsides  more  (|uicklv.  I  have  ireneniUv  ohserve<l 
it  to  disap]><'ar  duriiiir  the  middle  of  the  -wond  we(>k.  and  rarelv  to 
persist  beyond  the  |)eridd  ut'  detcrvcsceiiee.  Meteorisrn  develops  oiilv 
exce|)tionally  in  ca-es  of  typhus   fever,  while  one  must  ex]iect  the  occnr- 

reiK f  diarrhea   at    the  heie^ht    of  the  disea.se.   and   the  stools,   under 

the  influence  of  the  food  administered,  may  even  ;iC(|uire  an  appearance 
similar  to  tlid-e  in  case-,  of  tyjihoid  fexir.  With  resranl  to  the  diazo- 
reaction,  there  apjH'ar-  to  be  no  diU'ercuce  between  the  two  diseases. 
Also,  ill  caM-  dt'  typiiu~  fever,  which  ditVers  in  this  as  in  niaiiv  other 
conditions  tVoiii  the  ai  iite  exantliemata,  tlie  diazo-reaction  is  (rencrallv 
(leiiioiistrable  at  the  beirinnine  and  at  the  heisrht  of  t!ii>  fever.  It  inav 
be   mem.  lied    'hat    the   l"ukdcytc--  are   usually  increa-ed   in   number  in 

this     ecllditjull. 

Relapsing  Fever. — Cuifi'-idn  with  relapsini:  fever  is  mo,. 
likely  to  occur  with  rcL'iinl  to  typhu-  t'evcr  than  with  rcjrard  to  tvplioid 


g^ 


A\H 


ryriimi)  i  r.vi.n. 


fever.  Onl\  tlu' cariv  c.i-r^  in  ;ui  <[ii(i(iiiir,  :iiiil  (\\v>v  milv  iluriiijj:  tlie 
tii--I  t'rw  (Liv--,  riiiiM  cMiiM'  .l(.iil)l.  Hciv  and  tlicrc,  it  is  triie,  cunl'iision 
<it'  the  >e((>nc!  |i:ir<ixvsni  nf  relai)>in;r  lever  with  :i  rela]ise  nl'  ty|)h<ii<l 
lever  iniiilit  ari-e,  e^ix'.ialiy  if  the  fir.-t  |)iU'"X_vsni  faiieil  to  ediiie  under 
elinieai  nhservatinn.  l-'ven  in  sueii  a  ea-e  tiie  (U-i'a-e  cannot  readily 
lie  lonf mndeil  with  typhoid  f<'ver.  il>  oii~i'i  witli  a  ehiih  tiie  uini- 
.-nallv  iiiifh  teniiieratnre — up  to  11  < '.  and  ahovi — reached  witiiin  a 
>hort  time,  the  critical  decline  at  the  end  ot'  >even  day.-,  il.rely  later, 
protect  atrainst  error.  Natural!}-,  the  denion-tratiou  of  the  spirilla  of 
relap>in!.'  fever,  if  this  he  thoudit  of' in  the  .'arlie-t  eases  of  an  cpideniie, 
and  which,  as  i-  known,  can  he  found  durin<:  the  entire  febrile  ]>eriod, 
a  '  even  for  one  or  two  day-  heyond  (  Bireh-IIirsehfeld ),  will  remove 
all  .louht. 

Secondary  Syphilis. — The  eonfu-ion  of  the  eruptive  stajre  of 

:ceondarv  svphili-  with  t\  plioid  fevci-  is  more  likely  to  arise  at  times 
than  would  he  helieved.  The  he-t  (ihMTVer>  have  made  mi-takes  in 
this  cotmectiou  when  the  exanthem  of  s.coiidary  -yjihili-  ha-  made  its 
apiiearmce  with  remittent  fever,  eidartremeut  of  the  spleen,  and.  in  irri- 
lahK'  individual-,  even  with  jrenerai  nervous  symptom-.  >tupor.  ci<'. 

Trichinosis  ma\.  in  mild  ea-e-,  with  ])redominant  L'astro-entcritie 
svniptoms,  (|iiite  readily  he  contoun<led  w  ilh  irrejxular.  moderately  .-cNcre 
ca<es  of  tvphoid  fev.'r.  In  the  ]iivsence  oi'  severe  trichiuo-i-,  the  pain- 
ful tumefaction  and  induration  o|'  the  mu.-cle-,  the  iiexor  contvai'tnres 
of  the  extreiuitie-.  the  e<l.iua,  e.-|HHaally  of  lh<'  face,  will  ]>ennit  of  ii 
.ieei-ion  without  dillicultv,  A<  a  tinal  resort,  removal  of  a  pii'ce  of 
muscle  for  diairno-i-   ■      dd   he   indicated. 

Anthrax,  if  unatteudeil  with  carhunele  or  edema,  in  the  firm  of 
intestinal  mveosis,  with  the  attendant  symj»|oms  of  enteritis,  intestinal 
liemorrhaL''',  :>iid  the  typhoid  state,  mijrht  execptinnally  cause  dillieiilty 
in  diairno-i<. 

Acute  glanders  a!-o  is  suL't:<'^tive  at  first  <vz\\\  of  typhoid 
fever  if  the  patients  exhihit  remittent  t'cv  er.  a  ilry,  ti^-ured  ton>:uc, 
and  fuliizinous  deposit-  uiion  ili.'  lip-  and  the  <:um-.  (Jcuerally,  how- 
ever, the  characleri-tie  imi>.li,i:inous  or  ccthvmat.iu-  erujuion-.  multiple 
:,l,^,.es-e-  of  the  mu-cle-,  or  speeitie  idcerative  le-ion.-  of  the  mueou> 
mcmhrane-    will    lead    to   a    corre<-t    diairiio-is. 

The  diaLMio-tic  relati..u-  of  pncumonia  and  pleurisy  to  t\]ihoid 
fever  have  heen  >utViciintly  di-eu--ed  at  variotis  ])laees.  .\t  this  jioiiit 
it  mav  onlv  he  mctilioued  that  tlio-e  rare  ca-e-  of  central  ])neunionia.  ■■v 
;it  lea-t  pneumonia  1 -irinniui:  ;it  the  eenler  of  the  lunir,  may  at  times 
give  ri.-e  to  <'onfusion.  and  p.irti<Milarly  if  they  are  attended  with  stujior 


DIAdSOSlS. 


41'.) 


aiiil  (Icliritiiii,  uitlmul  [(Iciiillii'  |)aiii,  :iiiii  if,  in  ciitisciincticc  of  iiii|);iir('(l 
<'ons(iiiiisii('ss  or  (i(l)iliiy,  tiiiir  nature  is  not  iliM-loscd  liv  eliaracti'ri.stic 
exjK'ctonitiiMi. 


BACTERIOLOGIC  DIAGNOSIS. 

Tlii>  ('.\|M(tatii)ii  generally  lield,  after  tlie  diseoverv  of  tlie  tv|i!i(ii(l- 
bacilliis,  lliat  llie  dia^^n  i-i- of  the  (lisea.~e  would  lie  made  Ky  tlie  dt  nioii- 
stration  of  llie  ortrani-ni  in  every  ease,  which  many  thouj.dit  would  he 
a   i-olatively  simple   procedure,  has,  in    tiie   orit^inal    sense,  scareelv  iieeii 

realized.      On  the  i trary,  it  may  he  said  iliat  the  dinieidtie>  atienditii,' 

the  direct    dem<instration  of  the  haeilli   in   the  patient   or  hi-  dijeetions 
arc  e<in-ideral)l<',  and  in  some  cases  at  pn-ent  nnsui-niouutalile. 

DiflFerentiation  of  Bacillus  typhosus  from  Bacillus  coli. 

— The  ditl'erenliatiou  ol'  the  typhoid   i.acillus   isolated    from   the  excreta 


■le-  of   i'ood,  et( 


of  the  patient.  fi-oiii    su-|)icious    fluids, 
niicm-orLranisins,  especiallv  from   those  heh  -iLnuLT  to  th 


Irom  other 


th^ 


■^till 


itlicult    that    e\(n    at    III 


e   |in-eiit   dav  some 


c  eoion-i'rouii,  IS 


h,-erscr. a  xcrv 


-mall   nnmixr,  it   i-  iriie lill  maiiiiaiii  the  opinion   that   the   tw.i  are 

identical. 

As  a   mailer  of   facl.    the  LTeal    iiiorpiiolnL'ic  aiul    lii(ilu;.'ie   reseiuiilaiice 
helwecn   the   two    triictun'S.  especiallv   uilh    rcirani   In   llieir  form   ami  size. 


th, 


)lilil\ 


•IS  ilciieiu 


lent 


uiiou   the   prescnci'   nf  llairella,   their 


iiesrative 


response    to    (Jrain's    method    of   stainiiitr,    and    their    e(|uallv    reniarkahie 
resistance  to  carholii'   acid,  which,  when  added   to   the    iiit 


nine  nieiliuiii    m 


aiuoimls   111)  I.I  0.1'.) 


|)er   cent.,   does  not    jireveiit    their  developiuent.    is    a 


source  of  no  sinail  dithcully.      In  addition,  a  ^'real   ditficultv  in  ilie  isolat 


)f  th 
)lon-!; 


e  ortraiiism  arises  from  llie  alumdanl  presence  of  micro-ort;aiiisms  ( 


f  till 


rouu  in  tlu'  -In.. Is 
iiimerous  pnin 


iikI  tlicir  leiiilencv  io  invade   a 


11 


IS  of 


jiossilile  mlernal 


laid  down  as  the    resiili  of  many  himdreds  of' 
of  these  ditlereiK'CS  were  verv  iiuicklv  si 


ce   lielieved   to  he   relialile   hav 


e   been 
iiivesiijralioii.s.'  hut  not  a  lew 


low  II  to  lie  nic<)iisl;mt. 


The    following'    are    at    ])reseiit    considered    anioiiL:    ll 


criteria:      The   tlairella    arc   said    to    he  more  iiiuneroi;s  and   1 
lyplioid-hacillus   than    in    the    iiiici-o-oriraiiisms   of  tl 


le    more   valiialile 


oiiiTcr  in   tlie 


n'  colon-trroiii 


in    the 
to  be 


hanijinp;  drop,  with  suitable  precautions.  lyphoid-liacilli  are  I.elieved 
more  active  and  to  preserve  their  motility  for  a  loiiirer  lime.  While  the 
i'liaracteri.sti<'.<  of  liie  ;.r;-owlh  upon  u'clalin  and  a:.'ar  exhibit  sliL'hl.  at  times 
.scarcely  demonstrable,  diircreiices,  ihe  result.-  of  culture  iijion  jiotatoes  are 
fre(|iiently  more  cliara.'lerislic  ((iaffky).  It  was  formerlv  stated  that  if  one- 
half  of  a  disk  of  JM.iJrd  potato  be  iiioculatd  with  the  tOphcidd.a.'illus  and 
Ihe  other  half  with  tlu'  colon-bacijlus,  there  will  ilevelop  upon  the  latter, 
after  a  cerlMin  period  of  time,  a  den.se,  distinctly  visible,  at  first  vellowish, 
then   jrrayishdirown.  moisl.  {.disteniiisr,  smeary  coatiuir,  while  the  irrowth   of 

'  S,.,.   Ln<,.„,.r,    Arh.;t,;,  „„,,/,■„,    linrl,,.(i,,„„./l„;/s,„„t,;    H,l     ^i,.   ,,„,.  nf  tllPlnn-t 

c..iiipr.Oi.Ti-iv,'   criti.iil   imi»T>   iip..n  tlie  -iil.j,.,.l  ,.f  th.'  .litiVn-ritiiition  ,.f  tho  t\iili..i.l- 
lacillii-. 


•■fi?i 


iliiM 


4:20 


TYI'IIOHi   I  i.vi'i: 


1-1  ', 


liiil 


tilt-  lvi.li..i.l-l.!icillii>^  iipnii  till-  otlKT  liMlf  ;i|ii>fars  i.nlv  iis  ;in  cxtrciiulv  .li- 
,;lU..'iMni^I,  Mlini.sl  inins|.:livm  .l.-poMt,  .-..  lliiii  \\^■^\  Ml  tlMU>  it  cMii  l.r  iMcl 
up  uilli  a  ncfillr  (iiilv  in  lli-  Inriii  nf  innsi  ilclicalu  tilaiiHMit.s,  if  at  all  It 
i>  iinw  known.  l.oWfvtT.  lliai  llic^r  ailiercn.vs  may  lie  nuninii/.cil.  or  oven 
rntin'ly  ilisaj.iH'ar.  uiili  (vrtain  vani'tirr^  of  colon-bacill'  "a  ilial  iti.v 
,lc|«T,ii    lar-cly  al-.  upon  the    miction  of  tlio  Jiotalo,  so  ho  tt-st,  tlicn- 

fore.  is  noi  ..f  -nal  um'.  ,      ,       ,,  ,  ■  i        i 

S)ine  othrr  rullural  cIkh  :i.-trri>lii>  arc  \niiioiil,tc(ll>  -■■  lie  <  onMiler.Ml  a." 
more  irnslwortliv,  csp.  riallv  llir  -hamIi  in  litmii.s  milk.  Wlnlc  the  co^.n- 
liacillus  .■ausc>    llic    milk    to    l„c.uno    r^.pi.llv    ami    cMivm.ly    ucid    ami    1o 

un.l.T'o  roagnlalion.  tlir   tvpho„M,acillns  ilocs  not    .'aus. itrulalion  ot   tli. 

milk  an.l  ivimUt-  il  onlv  vrrv  laintiv  a.i^l.  even  if  il  It  kept  i"  lliP  tli.  r- 
mosiat  for  u.vks.  •flir  -Im-oM-l.'M  i>  not  less  valuaUlc.  It  ot  tuo  (IvM, 
hcnr.clicallv  .-calcl  i  fcrmcntalion-tlask.-<  .•oiitainin-:  Ln.;,p,..Mii:ar-l.onillon  tlu- 
„„,.  is  inn,.i,laI.Ml  with  the  typhoi.l-lmciUns  aihl  the  other  v\uh  the  eoloii- 
haeillus.  ami  l.oth  are  exp<i.<e(l  tor  twenlv-four  hoiii>  to  a  temperature  of 
■'7     (■     active   fermentation,  with   the   evolution  (  ♦'  -as.  will   .levelo])  in   tiie 

latter,  while  this  .lo.s  not  or,-,,,-   in    I >tlu  r    flask.      The  fermentation-test 

1„ mes  moiv  slrikin-  if  minlc  with  so|i,l  nuirilive  me.lia.      Of  two  j.'hieose- 

a-aror  L'luco.-e--elalin  tulo.  the  one  inocnlate.l  willi  the  typiioul-l.acillus 
remains  umhamre.i.  while  the  active  evolution  of  -as  in.lu.v.l  m  the  other 
l,v  the  colon-bacillus  elevates  t  lie  -.latin  from  the  l.ottom  of  the  tul.e  an.l 
L-iuscs   rents  ami   ti.-surcs  to  a|ip<'ar  in   llic   media. 

In  a.hiition  to  the  milk-tcM  a.Ml  the  f.'rnientation-test.  the  negative 
rcsiH.nse  to  the  in.l.,l-test.  f.rwhi.'h  Kitasato  ha.  descrihed  a  most  useful, 
simple  method,  appears  to  l,e  .piite  relialde.  In  -eneral.  the  colon-liaedlus 
vields  the  reaction,  while  it  is  wantim:  with  the  typhoid-ha.illus.  Hut.  since 
reckham-'  has  shown  that  hv  particular  methods  of  cultivation  the  lyphoid- 
hacilhis  niav  he  made  I,,  pr.'.dncc  indol,  and.  on  the  olh.r  haml.  that  unlesi> 
the  .•ohm-hii.'illns  he  -niwn  on  an  ahsolutely  sn-ar-free  mednim  the  develoj.- 
nieiit  ofimiol  mav  !.(■  prevented,  the  method  must  he  coi  sidered  of  i|nestion- 
ahle  value,  and  is  useful  onlv  when  taken  in  cmnection  v.ith  other  filatures. 
More    iinp.n-tant    than    aiiv    of  these    t.sts   in    the   .liflVrc'tialion    of    the 

tvi.hoid-hacillus  is  its  .-peciti,.  reaction  to  the  hi l-scrnm  of  immune  ammals 

and  of  tvphoid  patients.  The  use  of  this  method  i  winch  will  he  more  fully 
,iiscus.sed  later  in  cnshh^rin-  its  application  to  dia-uosis  ..f  the  d.sease) 
as  a  means  ..f  hacteriolo-ic  dilferenliation  w.-  owe  .specially  toi.rnher  an.l 
Durham,  wl...  api.n.ciat.'.t  its  full  vain.',  an.l  wlm  v.orke.l  ..ut  fully  the  .•.■u- 
,liti..ns  un.l.T  whi.'h  it  mav  h..  appli.'.l.  While  .h.uht  has  been  thrown  on 
its  vdue  as  a  m.^ans  .Z  ditrer..ntiati..n  bv  s.^veral  ..1  servrs.  who  also  (leman.l 
the  u.e..fextn.m.dvi,i-h  ,liluti..ns  ..f  th..  s.ri,m-ev..n  1  :  K.d.dDO  ami  ..ver 
—it  mav  b..  s:,i,l  il,at  v.h.n  tli.'  s..nnM.  .'V.!!  in  mo.hrate  .lilutmns,  is  c.ii- 
tr..ll.'.l  bv  ohs.Tvati..n  ..fit-  )H'li..n  on  kn..wn  lvph..i.l-ha.alli  the  test  is-piite 
constant  "an.l  •■xtivmelv  valuable.  It  nu.M  1-  emphasi/.-.l,  h..wev.T.  that 
„„  on..  t.'St  is  sutti.M..nt'f..r  the  .'..terminali..n  .-f  the  natniv  ..t  an  ..riranism 
of  this  .-roup,  an.l  that  ..nlv  when  all  tlu'  varh.ns  .hara.-teristi.'s  an.l  results 
.,f  .litl.Tent  t.-.sts  are  taken  into  CMnisi.l.Tati..n  .'an  a  .lelmile  comlusi..n  he 
reach.Ml  rnf..rl!mat.dv.  nun^ennis  .■arlier  statements  with  re-ar.l  t..  the 
presence  ..f  ih.'  lvph..i.l-ba.allus  in  th,.  livin-:  bo.ly  an.l  Us  excreta  have 
been  ma.l..  witlu.n't  cn.i.l.ratM.n  ..f  this  rul...  an.l  ar,.  theivh.re  valueless. 
.Attention    sh..ul.l   .cjain  be  .alle.l    (.,  the    p..ssibilitv  of  the  oc.urrence  ..f 

WfntralM.f.   lUU^   ",    rny.tsit..    fi<i     xiv,.   Ne,   1!2. 

^  Jijiir.  uf  Ext).  Med.,  v..l.  ii. 


j)iA(;s<)sis. 


Iiil 


Ihouscs  |irt'sc!ili!!cr  llio  '■lii!i'';\l  I'ii'turc  hC  tvpluiiil  I'.v.t.  Iml  wliii-li.  a.-'  dc 


liv  Mnnil-ciilliirt'S  ;iiiil  :iL'i.'liiliii;iti()M-lc>l.  :irc   |ipi1i;iM\ 


tllCt\  |lll 


iilii.-,  I)ilt  l>v 


DSflv  iflutcil  i)r;.'iiiii> 


ins.  I  In-  sii-c;i 


UU.-tMl  iiul    liv 


iiuracouiii 


illMl 


or    |i:ir:ity| 
(iwvii.'   Ciisliiii^ 


viiliokl-liiK'illi.       Such    liiicilli     Iki 


hffii    ilcscn 


hod 


Widal.' 


ScliiilIniiilliT.*     <»!licr   l)iicilli  iMtiTiiifdiiilf    lutwtrii 


thi   iv|>h<ii<l   and  CDlon  L'rini|i!<  an 


( i.irtner)  tvm. 


■ari'lul 


ha.-*  lifcii  ina 


If  hv  <  'iishiiiL'. 


I)MI| 

■Iht 


lit'  ihc    hoir-chii 

aralivc   -Hidy  (if  these   iiitoiiii 
'  hacilliis  lit' dvM'iiUTV.  thcsip-ca 


It-ra  iir   Hacilhis  eiiliTilidis 
fcliali'  tonus 


led  SI 


11 ''a  3 


liacilliis,  IS 


typlioi 


d- 


also  verv  e 
illi 


o>elv  rehiteil,  iiioriiUoloLrii 


allv  and  eullurallv.  to  ihe 


the    exael     relatioiislilii 


het 


ween    I  lie    two    (ir<'aiu>iiis 


tiowever,  not   hreii  coniiiletcly  uor 


ked 


out. 


Blood-cultures. —  rp  li.  williln   the   past   year,  enltiire-    I'mm    tlie 


hxid  have  lueii  lit' little  aid  in  diaLMi'i-is. 


Iiu>    niaile 


eireiilatint;  ti 

vi.!il-lv    -tated    ([I.    17-"ii,    newer    worl 

])i)S-il)le  tlie  denmnstratidii  of  the  ty|ili(iid-iiaeilli  in  the  einiilatintr  Mood 


with    Letter   nictliu, 


ill   7n   to   '*^<'   ]>er   cent,  ot 


ea^es    exannnei 


1.      (' 


irki 


at   tlie 


Johns  Hu|ikiiis  Ilo-pital,  ha-  lately  i-olated    the   liaeilli    fn.ni    \-\  of  oH 


eases  exainiiiett 


III  inaiiN-  of  the  ea-i  -  the  eid'iires  were  obtained  i 


arlv 


in 


th. 


ill-i'a-e. 


|..ri 


a    |io-ltlVe 


W'idal    te-t    had    lieeii   olitaim 


d.      It 


certain  ea-es  liie  eiiltllfe  alone  estal 


tile  (liaiTllo-l- 


had 


])re- 


vion.-lv   lieeti   don 


l.tfii! 


or    even 


I'teil.       Til' 


I'll 


le    tnetiiod    nsei 


1    i> 


Tl.e  ,-ki 


•r  the  anterior  -nrtiiee  of  the  patient's  arni  at  tlie 


lK>n<l  of  tl 


hen 
)U1 


)\v  Is  earetilllv  steriii/i 


i|.      'I'o  obtain  the  blood. 


iiiL--  S  to   10  e.e. 


1    titled   with  a   sina.U   needle  wliieli  will    readily 


enter  one  i> 


ftl 


ani 
•rtieial  veins,  is  used.      I 


iv  ii^ihl:  a  ~iiiall  needle  am 


ent< 


riiiL^  the    ein  with  one  thrust  little  or  no  puiti  is  eaiiseil.      Fnmi  S  to 

i  divided  alllonlr^i^^'  '"'  '^ix  Erlonniever 


d'b 


od  are  witlidrawti  ant 


each  contaiiiinL'' 


')0  e.e,  o 


:>oiiillon 


11< 


V 


ilaeed  in  the  men 


ibat( 


The  Hasks  are  tlien  .shaken 
after  tweiitv-fonr  lionrs,  if  eloiidv,  a<rar 


are  inadt 


|)lat( 

■luinped,  at  lea^t 


lallv,  the  ori.ranisnis  in  the  bouillon  are  somew 


I- hat 


tl 


le  scrnm-rf^aetion. 


iri-hb. 
The'd 


>til( 


<1 


not   suitable  for  tryiiifx 


lairiiosis  oi 


laeillns   tv'ihosiis   in   eael 


ihl  be  deeided  only  by  tyjiieal   <rrowth  on  all   media   and  by  afrfr 


hi- 


iiiation-tost  with  known  typhoid 


~ernni. 


V 


(jUf 


nth  .  a  fairlv  detinite 


eotu'lll-ion  can  lie  rea( 


hed  ill  thiitv-six  hours  after  obtaininij  the  enlture. 


If  tho  l)aeilli  irrow  e,nt  in  the  Doiiillon  in  twciity-tonr  hour 


tl 


lev  can 


traiisterr 
six  to  ei^^ 


d  at 
ht  1 


to  tl 


le  various   met 


lours,  a  siispi 
sertiin-reaetioii  can  be  triei 


lia.  ami  from  the  slant  r.pir,  after 

the 


I  suspension  in  hoiullon   can   be  nunle  in    wineli 


llf- 


1  /,„  S,-,„a!nr  M'-'l..  \wi.  4.  18;t7.  ■'  .l''linx  }t:'phins  Il.<p.  Il'dl..  v-l.  ix. 

'  Ihi.L,  vol.    xi, 

*  D'-ut.if/i.  mr,l.   M'nrh..  Avii,-.  \).  liKMt;  :,|^n.  Z'-il.  f.  Ilija.  n.   hii'-.  ii.l,  x.xxvi..  11. 
6  /,„r.  ,-,7.  «  Jm/.hs  n„/,khis  lloxp.  lUdl..  >■.•    1-4.  v.il.  lii. 


•1-J  TYrii'iiii  I  i:vi:i:. 

A  ltlliill;:ll  tlir  Ilictlii.il  |irr-rlll,-  <■(  .Ii-i.  Ii  r;il  .Ic  ti  ilinic;il  (litliriillics, 
will  re  llif  .finditioii-  arr  -iidi,  a-  in  a  liM-|iiial.  lliat  it  iiias  lie  (  rnli!ii\  id, 
il   i^of  iirnloiilitcil  ai'l  in  diaL'^iio-i-. 

Cultures   from  Rose-spots. — A-    inwicn-ly     lainl  (p.    17")), 

riilltn'r-  iiiaili'  Irdiii  llic  ni-t- -put-  have  -Imun  tlic  |ir(-riicc  nt'  ilic 
I\  |ilii'icl-liai-illii.-  ill  a  liiaj"iii_\  m'  tlic  ca-i-.  Tlir  in'crcdiiir  i-  iiol 
i<adil_v  a|i|ilicalilc  a.-  a  iiKaii-ut'  diairiio^i-,  In iwi  \rr.  mi  ariniint  nf  llir 
iti-rdiiiliift  til  the  |ialirm.  ami  al-u  liriaii-i'.  in  llic  ca-i-  in  wliicli  will- 
dt\  il'ipcd  fii>c--|Mii.-  arc  prcMiii.  the  (liairnn-i-  i-  ii-iiall\   ainadv   clrar. 

Al-o  puncture  of  the  spleen  <lurin'r  lite  i  I.iicaic  11,,,  (  liaiiicinc-.-c 
ami  \\  i,lal.  I;iilt,iiliacli('r.  !•",.  Nci--,  i).  \\  liicli  iiiid,,iilitidlv  tVc(picntlv 
\i,|,l,-  iH,,-ili\,'  fi-iilt-  (p.  ITHj.  lia-  1,,-t  all  .-i;^i\ilii-am'c  a-  a  praclicallv 
applii'ulilc  liiftlicd.  a.-  it  <'.\p,,-(-  the  |iati,iil-  clin,  tl\  t,,  daiiL'ir.  'Iliat 
ill  >,inif  ca-cs  lumbar  puncture — \vlii,li  i-  otun  imliiatcd  even 
tli'i'apeiitii'allv — may  facilitate  the  diiLriKi.-i.--  i-  cntirelv  pmliahlc,  and 
lias    liccn    vcr'linl    liy    illn.-trative   ease-. 

Ks|)ecial  hope  "a-  attiichoil  fn)ni  tlie  diitset  to  examination  of 
stools.  It  wiLs  soon  rccofrniwd  tliat  tiie  typhoid-hacilli  ( -cc  p.  '-Vl) 
us'ially  Iia\'e  the  hi,dy  ot'  tiie  patient  ii:  the  st,„,l^,  ami  that  lliev  are 
<liim,nstrahle  in  these  j:enerally  i'rom  the  iK'trimiiiij:  "T  the  niiiidic  ol' the 
second  Week  of  the  di-case  to  the  I'mirth  ami  even  the  fifth  week,  le.-s 
i'oniino;ily  into  the  p,  riod  followiiiir  deterveseenee.  Their  dernon>tra- 
ti,,ii  was  from  the  ,,ut.et  attended  with  the  greatest  difiicidty,  on 
a, omit  of  the  ininuiir-e  miniher  of  otlier  niicro-ortranisnis  at  the  same 
time  |)res('iit.  ami  especially  tlio-e  of  tile  colon  group.  El-ner '  has 
introihieeil  the  nsi',,f  a  s|H'<'iai  iiiedinm  tor  this  piir|io-e  which  has  given 
good  re-iilts  in  his  h.aiids,  and  has  i)ceii  w, irmly  ncommeiideil  hy 
I'rieger."  Lazartis.^  and  otliers  ;  liut.  on  the  other  hand,  lias  been 
declare(l  liv  others  ;  i'r,  net,'  Hacdke ')  as  not  entirely  rcliahlc.  How- 
ever this  may  he,  the  proetHlnre  re(|nires  the  greatest  .skill,  so  that  while 
in  the  hands  of  tiie  truiiieil  ohsf'rver  it  is  applicahle  f,,  the  solution  of 
certain  problem-,  in  its  present  form  ii  has  no  future  as  a  iliuieal 
niethoil. 

Eisner's  method,  lirieflv.  is  .t?  follows  :  If  1  per  rent,  of  iodin  is  added 
to  sterilized  potati,-i:elatin  of  lietiiiite  aciility.  and  if  jilaies  are  nuule  after 
a,iiiitioii  of  the  fecal  inalter  to  l,c  exaiiiineil.  it  is  possihle.  hy  the  adilition 
of  the  iodiii.  to  exclmie  from  lievrlopment  all  other  micro-organisms  hut  ttie 
eolon-bacillus  and  the  tvfthoiil-hacillus.  In  addition,  the  latter  develops 
distinctlv  more  slowlv  ami   i;icoiiipletelv.      While   in   the  course  of  tweuty- 

^  y.rif.  f.   Ilv'}    II-   l'!/-i''"tiyk..   IS'j:,,   H,i.  x\i 

^  Prntsrh    v>r,l    \V..rh..  IW.J.  Ni>   .00^         »  Bn-lin.  klm     II'.W,  ,  IS!,",  N„   40 

♦  /'<!''.,  IS',),;.   N'..,  47.  ■■'  I'nfsfh.  mr,f.    »'..^A  .  Is'.iT.  >',,.  2. 


Iil.\i:.\nsis. 


4'J3 


i;,ur  iH.urs  iioll.int:  of  tlic  lvi.l.oi.l-l.acillu<  can  l.c  seen  wilh  the  nake.  eye 
•ui,l  ^NUl,  Imw  |«.«ersnf  the' iinerosco,*.  afler  tlu-  la|,se  of  tnrly-eiL'lit  Imiir. 
It  will  l,e  presenl  to-elluT  vMth  ill.'  n.l(.n-l.a,illii-.  trn.n  viihl,  il  ,.  read. I v 
,ilsli>,.nii,.l,al,K.  uiMiiMhe  l^lale.  hi  a-Mili..,,  In  il.e  lar.'r,  n.urh  nu.r.-  n.ark- 
ea'lv  "nvi.ular,  l>r,.wn-roln,-,  .1  r,.lunirs  ..f  il,.'  lalter.  lli.-  nf  the  tnriuer 
appea'r  ad  siaalh  liri-hl,  irliMeHu,-.  exireiu.ly  IliKly  -ranuhir  ikuui.-^,  reseiii- 
hliiiL.'  ilrops  (if  water. 

Within   the    l>a-t    liw  yrai-   ..ih.r    inedi:,    an.l    -iie.ial   m.tho.l-    have 

1,,,,,,   i,„n„lu,r,l   hv    IUlU,e|•.>U^    uh-rfSer-.        The   .H.-t    p. UM.,-  of   th.^e 

n„.tho,l-  ate  tlinM.  ..f  l'i.,rkow-.Ui,  K.  ..in  .  and  Hi".  Kaeh  ,,f  th.M' 
nietho,!,  \m>  uiv,n  -00.1  n-iih.  in  the  hand-  nf  it.  author.  Ills..  n>in^' 
hi-  n.ethu.l,  wa-  al.h.  n.  i-.>hite  th.>  typhoicl-haeiih..  Inmi  IT  out  ..f  21 
,,.e-  in  .he  f.'hrile  -ta-e.  It  Mill  tvtnain-  U.  I.e  >een  whether  the  -.1- 
eral  r-mtine  ap|.li<atiori  <.['  the-e  nietlxKls  i-  pra.tieahle  or  imt. 

A<  previon.lv  -tated  (-ee  pp.  .'.  »  and  I'.ttl),  typii.ml-l.aeilli  are  found 
i„  ,i„,  ,„.i,„,  i„"alM,nt  one-third  of  the  ea-es  examined.  While  their 
presence  i-  rare  hefore  tile  third  week,  they  may  .leenr  d.iri.ijr  tlie  s.v.md 
w.ek,  or  even  the  en.l  ..f  the  tit>t  ueek.  and  -n  their  i>olation  may  he 
of  definite  dia^mo-tie  value.  In  making'  enltnres  female.  .Imnld  he 
eatheteri/ed  under  eareful  aiiti.eptie  preeaiitioii.,  ami  the  urine  ... 
ol.taine.1  -houhl  1m.  plafd  at  onee.  In  males,  the  anterior  iiivthl-.r 
-hotihl  he  irri,t,^ited  with  aiiti.ei^tie  .oliitioii..  ami  the  patient  should  then 
void  into  a  sterile  tlask.  In  the  .hterminatioii  of  a  haeilhis  ohtained  in 
the  culture,  ^rirat  care  should  he  taken  airain-t  eonfonndin^r  ti,,.  typlioid- 
haeillns  with  the  eolon-haeillu-,  to  whieh  ey^itis  is  .|iiite  commonly  <lne. 
Attention  should  a^r..,in  oe  ealle.l  to  the  ptviiliar  shimmer  de-erihed  hy 
Ilorton-Sniith  which  is  seen  when  a  te-t-tnhe  tilh'il  with  urine  containiii<; 
larir.'  niimhers  of  haeilli  is  held  nj)  to  the  liirht  and  ireiitly  .liaken.  In 
this  wav  the  presence  of  the  eoiulition  can  often  he  predicted  hefore 
cult,  f'.'s   have  heen   niadi'. 

METHODS  OF  SERUM-DIAGNOSIS. 

Within  the  jiast  few  y  ;i  an  indirect  inetliod  of  hactcriologio  diajj- 
nosis  ha.-  i)eon  introdnciMl  which  has  proved  to  he  of  prreat  value. 
While  this  method  of  serum-diajrnosis,  owiuir  to  the  fre.iuently  delave.l 
ai>pe^ininee  of  the  reaction,  has  not  heen  found  to  he  of  so  <rreat  value 
as  was  at  tlrst  h.>pe<l,  it  is.  nevertheless,  an  exceedintrly  imptrtant  factor 
in  dia-rnosis.  This  method  is  hased  upon  the  fundamental  investiL'a- 
tion.s  of  R.  Pfeiffer'  and  his  piqiils,  orii:inally  undertak.'n  in  the  study 
of  the  question  of  immunitv.  These  investigators  stndie<l  the  action 
of  t'-.'j  hlood-serum  of  animals  immunized  to  cholem  and  typhoid  fever 

Zeit.j.  llyg-  »■  Infektiunsk.,  Bd.  .xi.x. 


IJl 


•/•)  I'll"!!'    I  IVI  i: 


\^% 


iipi'ii  llif  I'l -]iccli\c  |i:iilin._'i  iiic  niiri-.p-iir;_Mii  ni-.  'I  lux  -lii'Wid  c  .-iic- 
fi:ill_\  i|'tiill'(l'  :illi|  Knll(')  lli.il.  I  \:ii  ll_\  a-  ill  llirci.-r  nf  rln  lii  l;i.  llic 
.-(•niiii  i>r  aniiii.il-  iniiiiiiiii/'il  !■>  ly|iliiM(|  l(\  i  r,  \\\\<\\  |il;ii-.(|  in  i|i,. 
al"liilMiiKil  cavily  i.t'  :\  |irc\  ioii-l\  lualiliy  <\|"  riimnlal  aniinal  iLjiiiiic'a- 
]M,L'),  tii'jfili<r  uitli  an  anh.iinl  of  i\|ili..al  riilim-c  i  Ap,  i  inn  nlalK  ililri'- 
liiiiiiil  to  l(c  t'alal,  lint  ainiic  |ini;i(hi|  ilii-  animal  airain-l  llir  ai-iinti  nf 
ilic  liacilli,  lint  al-u  imliiccil  L'i'aiiiilar  (lc;.'riifi-atiiiii  n|'  tin  lalirr,  and 
tiiially  '.lirlr   (■(iin|il(lc   M'lnlinii. 

The  Pfeiffer  I^ysogenic  Action  of  the  Immune  Serum. — 

Aftt  T  llic  I'li'illir  .-chiM.l  had  wiili  (crlainlv  dciiiiMi.-lratrd  liii-  '' 1\ -n- 
i.'rnic  '"  ai  ijnn  (■!  llir  iininnnc  ->  rniii  In  lie  specitic,  it  liiadr  the  iinpnrtaiit 
a<lvani'i'  nt'  i>iaMi.-liiiiL''  ilif  pr"(i  ilnrc.  not  alone  a^  (nic  ini])ortani  in  ils 
licariiii:  oil  ilif  (|H(,'.-iion  ot'  iniiniiiiily,  liiit  al>o  as  a  ino.-t  availaMo 
iiiftliod  ot'  dillci<'iitiatioii  of  iiiicni-orL''aiii-iii>,  |iaftii  nlailv  of  the 
typlioid-liacilhi-  i'foin  flic  nii!iili(r'-  (•!'  tlic  coloii-i.rroiip,  wliicli  liad 
liitlifrto  licin  <loiir  liy  diirrt  <nllni-i-inttlioiU  onlv  wiih  nindi  dilliciiltv, 
and  then  ii^it  w  iili  rcrtainix . 

A  liiriliri'  iio|c\\(  ,rtli\'  ad\aii<r  in  tlii.-  ciiicctioii  coii-i-tc*!  in  tlic 
d^'llloll^tl■alioll,  inautriiratcd  li\  larlirr  ill\•(•^liL'•ations  ot  I'I'citlci'  aii<l  liis 
liii|iils,-  .Mci-iliiiiUotl'/  l!(.rdi  I,'  anil  otlirr>,  that  the  reaction  ol'  I't'eill'er. 
at  fir-t  iielie\-ed  to  neenr  only  in  the  Ixidv  ol'  tiie  liviiij;  animal,  cimld 
bi'  lililaiiied  al>(i  under  certain  condition-  in  the  test-tnlie. 

The  Method  of  Gruber. — The  intiodnction  <ii'  the  mctliod  into 
]>raeti<'e  was  ed'ected  finallv  tlironi:h  the  important  latior~  ot' ( irnher  and 
Ids  piipiU.'  who  furnished  cxiili'iice  that,  in  the  >anic  way  a>  the  Mood- 
sernni  of  an  iminnni/ed  animal,  that  ot  a  human  liciii^,  alter  recovery 
from  tyjilioid  fever,  hrou^ht  toj_rcthcr  with  a  culture  of  typlioid-iiaeilli  in 
a  tcst-tulie,  soon  render-  the  haeilii  imiuoliilc  and  eau-estliem  to  ayjrre- 
Lrale  in  the  form  of  clumps  and  to  he  precipiiate<l  in  the  form  of  a 
Hoeeiileiit  sediment  (airirlut illation ).  I'fciU'er  and  KoUe'^  luid,  inde- 
|)endentlv  of  •  inihcr.   ohtained   similar  results. 

Ill  the  historic  consiilcration  of  tlu>  entire  (picstion.  it  is  of  iniportanic  that 
rinilHT  at  oncf  cnipliasized  tlie  fact  that  his  inethod  nf  ai:;.dntiiiation  e.slah- 
lished  not  .ilnne  the  ditrerpntiiilion  nf  the  typh(iiil-ha<'illiis  from  sinnlar 
hacilli.  hilt  that  it  was.  furthermore.  cai>alil(>  of  furnishiii;.'.  directly  from 
the  hl.xid-seriini  if  a  liuman  licin<:.  proof  of  the  previous  p.xistence  of 
typhoid  fever;  thus,  of  niakincr  the  diairnosis  suhseqiieiitly  or  of  contirniiiif; 
it  if  already  made   I'linicallv.      TluTpfore  to  (iruher.  ami  with    him   to   his 

1  /..t,,\    ;/,..,;.  „.   l,'/-!:' !:..   IM  xxi.  •  I -ipIV  nn.l  T^.lIl'.tT    I  ■,'■•1     71.1     xvii 

■'  Aiinnlrx  ,lr  riiistifii'  I'asfeur.  ISO.'i.  '  //.,'./..   IS'.i.'.. 

'  Wini.  Win.  ir.  .-/i..  18;»'i,  N'c'^.  11  ami  I'J.  (('•rul'T  mid)  Durlmm.  I'mcrediiips 
of  thr    Rnynl   S'irirty.    .I:inii;iry   ".    IS'.ii;     vol.    lii. 


\fi' 


l>l.\<i\n.<IS. 


l-_'."< 


,,,,,,,1.  (Ini.il.nmn.'  I.Moiil'S  iIr-  yr.Mlit  ..f  l,:iviii.-  ."ill.^l  attention  to  tlir 
,li:iL'n..>lic    utility   ..f  -fruiii-fXutiiiMali.iii. 

AllhoUi:li  (Inili.T"-  ni.'lliM.l  wa-  at  tii-t  only  ivtro-i"ctivc,  it  \va~ 
,,l;,l„,r:it,'.l  l.y  Wi.lal^  in  -.  far  a-  li.  fm-m-la  .1  |.n.,.f  that  tli.^  mTIIIii 
r..iM..v.l  (■\liilpit.-.l  Ihr  -am.'  aLvlini":"'".!:  mUn.'iici',  ik.I  al.iiic  atUr 
PM-Mv.rv  fn.Mi  typlioi.l  tiv.r,  l.ut  A-n  in  tiir  1..  .;imiiiiL' ;iii'i  at  the  li<-if:lit 

ut'  th.'  iliMM^c.  .\r,'..r,lili-ly,  it  is  [M,.->;i.lr  to  r-taLli-ll  the  .xi-t.'ll.-c  of 
ill.'  ili^ra-^.'ilirrctly  liy  mk  an- .if -.■riim-<iia^ii.i^i-,  not  alone  ,-ul.-r(iiieiitly, 
lint  also  iliirint^  its  pro^ri-,.-,. 

\fler  Wi'lal'i  clalioratioii  of  ilie  ,lo,irine  of  (irulM-r  had  receiveii  ahun- 
,lant  .•onlirmatioi,  ni  Kran.v  <  •haMl.-Mie>-r,  Dieiilaloy,  I.eiuoiiif,  Arhanl, 
Catriii  M.Mioti.T,  an.l  Sin-hA,  Wi.lal  ami  hi>  |,ii|.il.-  ,  hi>  -talcnuaits  led  to 
the  iiicTi.tion  ot'  a  nuiiiher  of  i„v,-li-atiwn-  al-o  in  (  ...rn,an>  W  iti  >liL'hl 
.iiireren.vs  in  (h^tail.  thes.^  a-iv.-,!  «ilh  the  ivMill.-  ol  (.niher  and  W  idal 
and  .■onlril.uted  materially  to  :l,r  lurlli.r  dev ,  lop.neul  an,l  Minphtieation  of 
the  method. 

The  Widal  Serum-diagnosis.— Ilie  Wi.lal  -enirn-exaniinaii.m 

as  ._r,.iierallv  pi-a.^ti-..!  at  i.rr~.nt,  an.i  a~  it  ha-  Imcii  -ervicalde  al-.>  it! 
,nv  .■lini.'   "in    a    hii-.'    iiumluT   .d'  .m-.-.  i-   eame.l   out    in   the  loll..\vini,' 

iiiann.  r  : 

Blood-abstraction.— I'he  1,1. ....1  i-  al>-tia.>t..l  either  «lil-eetly  tVoiii 

the  ni.MJian  vein  .d'  th.'  pathut  to  he  e\aiiiine.l,  l>y  mean-  .d'  a  -tefili/.ed 

livpodennie   -yrin.:.'  .t  hy    the  appli.Mtion  ot'  a   euppiiiLr-Lrla-s  aft<i-  a 

nif.iher  of  in.  i-i..n-   liave   he.  u    made    int..  the  -Uif       Smaller  am.. iints 

of  l)h""l  from  til.'  tiji  ..f  th.'  linirer,  ..r.  l.ett.r   -till,  ff., in  the   l.il.ule   .if 

the  e'ar,  whi.-li   are  .pii.'kly  -eiit   t..  the   lal>.,rat..ry  in   a   sterile  eiiitiire- 

t,il„.  ,,f  i>i(hnil.le  si/,.,  are  a.le,|nate  in  iirivat.'   praeti.e.      Th.'  Id 1 

olitain.'.!    i-   inIrodu.v.l    int.,  a   iiarr.,\v    test-tulte.  uhi.'li    is  tln'ii   plaeed 

ol.li.pielv  f,r  -e(lim,ntati.,n.       If  tlii-  d.-es  n.,t  tak.'  jilaee  e.,mplet(dy,  so 

that  the   -eniin  .iverlvino;   the  lilood-.  hit  still  e.mtaiu-  re.Mil.x.d-cirpus- 

eh        !iis  will  not   inti'idia-e  with  the  i'lirther  investitrati.m,  as  ev«n   (lrie<I 

'  Sit:iiiU!xfi.  d.  Wifshnilrner  (■■,!i!jrr.t!i.  /.  iini  V>l  .  April.  ISW.  and  tlio  I.anret, 
Si>yit.  I'.l,  IH'.IC. 

-  Setn.  in<y.,  lS!if,.  No  ■X"  f'.nnpnn-  al^o  Wi.i:,!.^  lii-t..ric  it.-s.Tiption.  .Uu«cA. 
med.  Woch.,  18117.  N.,.  8.  licport-  of  til."  r.'iiiiiii.im:  Freneh  investigations  are  con- 
tain.'d  in  .S>»i.  mid.,  1806.  fnnn  Aiiu'ii-t  to  N.>v(>nil.'>r. 

'  lireuiT.  Prrlin.  klin.  W..rh..  IS'.i.;  No^.  47  an.l  48  St.Tn  r,;,trn!hl .  f  urn. 
Med..  1806.  No.  40.  and  1807.  No.  11.  Ilii.'dko.  Dnia.-h.  med.  Wnrh..  18',I7.  N".  2. 
C.  Frank.'l.  DeuLvh  med.  W'ueh..  1807.  N..-.  3  and  16.  .^>'y..  !»')>».  med.  Wneh  .  1807, 
N...  3.  I'irk.  Wien.  klin.  \Vn,-h..  1807.  No.  4.  K.,1Ip.  Deut^eh.  med.  Wi^h..  1S07, 
No.  0.  (Inili.T.  Minieh  n,rd.  \V..r)i..  1807.  N.v  17.  I.pvy  and  r,i.«*l.T.  Munrh.  med. 
H'neh..  1807.  No-  oO  and  .M,  I)u  M.--iiil  d.'  Kochi-mont.  Munrl,.  med.  U'oeh..  1898, 
No,  .-,.      E.   Krankcl.  Ihid 


r! 


■i-2t; 


TVrilnlli  Fi  vr.ii 


I'l I    ni.iiii-    it-    ;i'j-L:liiiiii.iiiii;.'    |Mi\Mr       -A    www    lie    ctriiilMM  i|    in    ;in 

Mill  r:;iiii  \       I  W  iiLil.   Sic-ni    iiml    ['..r-tir,    .I'Jin-inin. 

Macroscopic  Method.  Il  -.m.  ,.r  ih,  -.  ruin  llm-  ..l.iain,,!  i.> 
IiNin-r.Ti't'il  liy  tiicaii-  "t'  a  |>l:iliiiiiiii  \>"<\<  i"  -iaiiviI  iiiKir  cc  ni  imrh  ix 
lit'  l\|i|ioi,l  lM.iiill.,n-riil|iir.'.  |i|i  t'll'.ililv  iii'l  Ih.ii-i-  lliaii  Iw.Ui  limir-  i.|.|, 
ill  a   nan  i.w    I. -i -Inl"  .  ainl   il'   lii.    inl\lhi.-    Iir    fA|iM-ii|    li.    a    li  in|'i  raliiir 

■l'  -iT      (   .,   ni    till     li.nr-.    ..l'  t'l"tn  lliri.    n.  -.s.  n   1 i-  llir  li  .riiial  ii  iii  I't' 

tlaki-  ami  liauini  iil-  lnLriii-  li.laki  |ilaii  in  tin  |p|'(  \  i.  ■ii-l\  niiilnrniK 
liiiliiil  lliiiil.  ami  llir-i'  -(«.ii  -i-illr  lo  llic  K.illi.ni.  Al  lln-  nul  nf  luiiilv- 
t'l'iir  Im'Iii--  ihi-  -i|iaralh.n  "I'  llir  ti'M'.iili  liMin  lln  tliii.l  will  he  coin- 
I'li  li'l.  -"  llial  tin  Iminll'in  "\  1  rh  iiiu  til'  1  riiinliliiiir  \illi'\\i-li  -iiliiniiil 
will  lia\c  Ikcmiiii-  riili|-tl\  rlcar  ami  lia\i'  n  LTaiinil  it-  iii'ii:iiial  ri'l"!'. 
M  il  li.-rii|iic  I'xaiiiiiialiiiii  ili.-clu-i-  that  I  lir  -I'liinirlll  n  iii-i-l-  -nlcK  nf  tli(> 
i!ct;ilirfalf(l  illlil  (■iijirrrnt    liarilli. 

Knr  till'  liiiriiiiiir,  tlii-  tr-i  l.iTnnii-  oiicrially  ili.>liiiriivf  if,  ln^rillirr  uilti 

llii'  il iilalfil  lultiiri-.  iiiii-  i>  |iirpairil  In  wliicli  Miaiin  lla^<  mil    liccii    aililcd, 

ami  wliirli  lluii.  ill  rnii-i  .|iii'iic-c  III'  till-  iiiiili>lurlici|  ami  |ii'i>i.-liiii:  active 
imitililv  ami  iinitiirin  ili^trilnitinii  nf  tlic  liarilli,  i-rlaiii.i  ilf*  |iiiiiiar\   turliiililv. 

Microscopic  Method. — 'I'lif  iiiairi.-(ii|iir  |iii.im  ilnri'  i-  n-.t'nl  mily 
an  a  |)rriitiiiiiar\  ti-t.  It  i-  iiintr  ninvfiiiriil  ami  iniiin  nftaiii  In  |irr- 
tiiit    till'    |ii'ii<T--  lit'  aLiL'^liitiiialiiiii  In  takr    placf   lirmatli  the   iiiiiT(i-cii|i(', 

\\  tlill     till'     clltll'i'    |iri  iri'illlfr,    wliirll     take-     |il,acr     ill    tllrriilir>l'    iit'   a     t'rW 

ininiiti-,  ran  In-  \ii\\ri|  in  iji  tail  ami  iliriTth.  W  iilal  riiiiiiiAcd  tliis 
|iiiiiTiluri',  anil  in  tin'  liaml-  nt    -iili-rijiiriit  mIi-ima  n-  it   lia-  liirti  j^natlv 

jicfti  Ttril. 

'Illi'  -ilii|ilr-t  tniiilr  III  ]iriircilliri'  i-n|i-i.-t-  ill  aildilli:  tlir  -rrillil  til  Ik! 
tc-tcil  til  a  iMiiiillnii-riiltiirc  nt't'inin  ten  tn  lint  iiinri'  iliaii  liLrlitccii  Imiirs 
njil.  .iml  -IiiiKiiiL''  tlif  liatiL'iiiL:' ili'i'l'-  It'  tlw  Mriiiii  i.-  drrivcd  iVniii  a 
t\|ilinid  ]iatiiiit.  i-|irriall\-  ,il  tin'  In  i^lit  nf  tlir  tilii'iir  -Iai;f  nr  a  iairr 
jvi  rind,  and  il  a  -ntllriiMit  ainniiiit — almiil  an  ii|iial  |iart — nt'  M-nitn  lia.s 
liiili  added,  tlir  li.irilli  \\ill  lir  -rill  i  III  liiid  iatt  l\'  at'trf  the  aiilnixturi-  tn 
lirrniiic  iininiiliilr  and  tn  inllcit  in  iliiiii|i-  nt'  vai'yiiiL''  >izi'.  \^  iiili'  tlir 
fiitirr  tii'ld  nt' \  i-imi  rrinain-  iinirnnnK  nrrii|ii(il  li\' tlir -wariiiiiit;  liarilli 
in  a  riintfnl-iirciiaralinn  tn  wliirli  im  -i nun  lia-  lirrii  aildril.  llial  tn 
wliirli  iininiinr  -cniiii  lia-  linn  addrd  ivxiiiliit-  laru'r  area-  nt'  the  \'i-iial 
til  Id  tliat  arc  rlear,  with  the  a^e;iinilialei|  elninii- enlleeled  niilx  in  certain 
place-. 

'  Natur:ill\.  11-  will  iii.|i.'Mr  fr-iii  wliai  r.ll-\\>.   if  .Iri.il  til I  i-  t..  1 in|.l-M-ii  f..r 

purjiiiii--  rif  r\-Av\  lii'tiTiiiiriati  .?!.  it-  :iiii"nnt  -IimuM  I"  iim:i-iii-''iI  In  I'.iri-  it  i-  lirii'il,  iiml 
hi  I'lp'  1..  inu'  niiiil-'  ii-i'  "I'  it  -h"\ilil  111'  ini.Ni.'d  witli  iin  arciiniti-ly  (iitiTiniin'il  Hiii'iUnt 
of  |)li\ -i-'li'L'i''   .-all   si.liitiiiii. 


M 


;>/.!(.■  .Vo.s/.s 


JJ 


]-\.r    .liiiirMl    piir|M.-.-    ill.'    iiii(io-(o|,ir    |if.H-,-.liir.-   Ii;i-   .uliivly   .li  — 

nl.ic.d     llli'     lli:irr..-.-,.|,ir.   ,>|n.i;llly     l„ran-c     il     .ll"llr     i~    iMpalilr    ..r    I'ul- 
llllii,-    ill,.    |v."L'iii/r(l    ii..i>-:ii>     n,|uin'iri.  ril,    ii;iinrl\.    tlir    (l.l.iiinija- 

li..ii  ..!'  tlir  LM-ralr-l  (li'.'iv.'  .pf  ililiili I'  llir  -«  i-uiu  that   ill  a  -ivi'ii  .■a^^■ 

will  Irad  t.>  til ■(■ilfiTli'v  .if  a-i:liitiiiati..ii. 

The  Earliest  Appearance  of  the  Reaction.— In  lii-  .arlic-t 

[mMh   iti^'il-  Wi'lal  -lal.-.l  lliat   llir  a--liil  iiial  liiu  a<ti..ii  nf  tlir  -criim   ,,f 
tVj.liMMl    i.atinil--   .■.,iiM    !»■  .-lirii,,!  a-  ..iilv    a-  tli>-  ni.l    c,f  lli.^  tii-t   wnk 

,,t' till'  ili~i'i-i'.       riir'fliinalrlv  ,  llii-   -tail  nil  lit   lia-  iml  I ii  ulii.|l\   c.ii- 

tii-iii,.,i.  Oil  the  c-Miitrar\,  it  wa-  ImiumI  u  il  Ii  L'r'.uiiiL;  .  \|m  ri.iicc  lliat 
llir   -.•niiii  ar(|iiliv.|   tlial    iin.|Mriy  ..iil\    in    tli.'    iiiin..rily  ..f  ca---    l»tuf.' 

thr    l.Tiniiiatinn   of  tlic  lir-t  w.vk.  -t   riv.|ii(nily  nd  inilil    the   -.■.•mi.l 

wr.k  (tVoiii  ilir  -cvnilli  In  llir  I.  Ill  li  <  la_\  ),  uliili'  faivly  it  u:i>  ■Irl-.iycl 
l.ryniid  llial  liinr.  (Aril  to  laid-  wok-  (Stirii,  Koll,,-  I'.lutiinilliar). 
Coiiilil.lr  ati-cncc  of  till'  ivartioii  i-  one  of  tlic  ran-I  txcijilioii-. 
Ainoiit:  a  laix^'  iiiinilMr  of  ca-.-,  in  only  t"o.  wliicli  wdv  -liown 
1)V  aiito|i-v  to  he  in-tanr.-  of  typlioiii  tl^.r,  liavr  I  failf<l  to  ol.-crvi- 
ail  tmclonlit.a  ivadioii.  N.vciiliric",  il  -lioiil.l  \,v  liotnr  In  iiiiml  that 
the  al.-cnci'  of  aL''t;lntinalion  ilnriiii:  the  fir-t.  ami  even  in  the  ipcirinniii;: 
,,f  the  -cimpikI  wtrk,  is  not  fviiiiii.T  a<:ain-t  llif  cNi-l.nci'  of  lyi.honi 
f.v.r,  an.l  that  in  onl.T  to  ol.tain  ivIiaM.'  rt'-iill-  tliv  .xainiTiatioii  -iioiikl 
l.r  rc].cat.(l  al~o  (liiriiii,^  ihc  fnrtiicr  .■oiirx'  of  the  ili-casc  at  il.'fmil. 
inlcrval-  of  not   too   ^Tt'at    lciij;th. 

Specificity  of  the   Reaction. — Xatiirally,  thf  (luotion  -ooii 

arose  whether,  i-  a  matter  of  fact,  the  hlood-eniin  of  typhoid  [.alieiit.-i 
alone  |)o->es--ed  the  afrjilntinatinu'  intliieiiee  on  the  ly|)iioid-l)ae:lln.~,  and, 
if  this  he  not  thf  ease  exehi.-iveiy,  wheth.T  thi-  |.roiM'i-ty  iiii^dit  not 
he  pos.-ossed  exee]itioiially  ami  in  lesser  deL'-fie  hy  sernin  from  otiior 
patients  -iitVerini,'  from  other  disea-e-.  It  \va>  -oon  found  that  the 
reaction  oiciirs  even  diiriii;;  health  (Stern ')  and  in  the  iireseiur  of  a 
nilinher  of  di-ea-e-,  ajipareiitly  es]ieeially  in  aeiite  infections  di-iases, 
>o  that  for  a  time  the  diafrnostie  value  of  the  procedure  ap|>eared  to  he 
dimini-hed  hv  tlii>  fact.  On  further  invotiiratioti,  however,  it  was 
found  that  under  these  conditions  the  reaction  takes  place  only  when 
eoin|>arativcly  lar;;e  (iiiantities  of  the  seriwn  to  he  exaiiune<l  are  added 
to   the  culture. 

Since  Widal's  first  piihlication  thousand-  nf  examinations  have  boon 
diri'cted  to  this  point,  and  all  have  yielded  ap]irfixiniatcly  like  results.  Tt 
has  l)ecn  fmind  that  tlic  occurrence  of  afrjrlntination  with  equal  parts  of 

1  CrntrnJhL  i    nui    M,;l..  ISim.  Ne.  49.  ■'  P'-'itsrh    nii-,!     Il'..r-A..  1K07.  N'm.  ;>. 

«  fA,',/     1W<.-    \.,    1.-.  *  rWj/r«/W.  r.  :«/i.  iVf</,,  18%.  No.  49. 


M   -■'. 


42H 


I  Yllhlh    I  I  Vll: 


till  I 


HI 


mr-^ 


wrillll  IIhI  .  nlllllV,  I  \  rll  olir  ..r  -1  fllhl  !■.  I.  11  til'  riilnin  ,  i-  lit'  il-i  It'  licit 
ciili.  lii-i\i-  ..I  l\|iliiiii|  li-vcr  ;  ami  liiillni,  tlial  tin  il.  \  i  I.  .|.in,  iil  ><\'  tic 
rcai'tiiiii  v\illi  a  ililiitinii  ul'  mii'  in  I\\iiil\.  r\iii  nin    in  llmiv    aiiil   mii'  tn 

liiflv,  iua\   al ri  iir    iiml.  r  ni  hi  i mlii  i.  m-  ;    \\  liilc  a  i"  i-il  i\  r  iiaiiiuii 

uiilia  ililiil  i'lii  111'  ilh'  -1  riiiii  111  \.. ml  mn  (,,  |iiii\  niciii-  allim-l  i  mIii- 
-l\  lis      ill    r:i-.  -    111'    I  \  |il|.i|<l     li\  rr.' 

'  iiulur  ami  ( iriiiilmiiiu  '  anil  Stern  '  were  ninmi'  lln'  flr-l  tu  ilircct  nllcn- 
tiiiii  I"  till-  ili.-tiiKliM'ly  ini[mrlaia  a>|iirt  of  llif  i|iii^ti(iii  ;  ami,  atiiT  lliciii, 
f?|itiaallv  Krcmr.  < '.  P'rankil,  I)ii  .Moiiil.  ami  l-'iii>tcr.'  'I'liat  iiIm.  mixl- 
urcs  aliiiVf  1  :  Jn  ii|i  to  1  :  Id  arr  nut  rcrtaiiily  imiiiiitnc  nt'  lv|ili  iil  \V\vt 
lia.i    liciM   ••liiuMi   i>|HM-ialiy    liyvan    <  M-c||.    Kiihiiaii."  /.irinkc."  SlicH'iT.    ami 

ntlllTN.         Al  riTilillL'      In     IIIN      iHMl      niirTr\aliiill>,     Hllcll     lli.'ll     ilillllilill,"     lit'     the 

.-iTUin  air  liiit  ran  ly  I'lli'luc  in  ilic  |.ri«i'iii  <■  ••(  nllirr  iiit'ii'li  u-  ilisfiiM'.--. 
Stern'  hail  |ire\  iiiii,-l\  |.iihli:-hei|  the  i\ai  t  i-i>ull<  nt'  exaiiiiiialions  in 
Tn  rases  nt'  nther  ilisea.-es.  ami  ~iil.,-.i-i)iiiiill\ ,  in  inninmlinii  u  ith  .'••kinwer.'"  in 
lull  i-a.-i-.  AniniiL.'  the  laller  there  v^.re.  L'n  in  wliiih  a  re>|inn>e  tn  1  ;  10 
wa.-  nlilaiiii'i  :  H'  in  v\  hirli  a  n  s|inii.-e  tn  |  :  _'ll  «a-  nhianieil  ,  L'  in  w  liii  h  a 
re.-|in||-e  In  I   ;  .Id  um>  nhlailleil  .    I    ill  «  liieli  a  re-| se  In   1   :  K)  was  nhlailleil. 

Diagnostic  Significance  of  the  Quantitative  Relations 
of  Scrum  and  Culture.—  iM-nm  tin  inivnninn-  iIm'  liiipnriaiit  I'mieiii- 

.sinii  ean  lie  drauii  that  the  i|;aniin-tir  utility  it'  ihe  ( inilier-W'iilal  reac- 
tiiiii  i-  iie|ieiii|eiit,  aliiive  all  thiiii;-.  ii|iiin  a  carel'iil  eniisiiicrat  inii  nt'  the 
i|iianlilalive  ivlalii  The  -mailer  the'  aiimunt  nf  seniiii  iieee-.strv  I'nr 

till      ile\  eln|iinelU      nt'    the     reaetinll,     the     Mmre     eel'taill     is     tile     (jiaj^lKlsis. 
TIlllS     it      ha-     lieell     t'liliml.    nil     t'lirlhel-   stlldv    nf    the  enlKJitinll.    that    at 

time-    the    leaeiinM    may  lie   nlitaimil  \\illi   alinnst    iiiereijilily  hiixh   dilu- 

'  Till'  imali^iN  fur  till'  I'XHil  preimrulinii  ami  tin'  f)uiintitati\  i'  ili'tiTniiiiatimi  nf  the 
nnxtiiri'  nf -•■niin  and  enlturp  iiinnut  lie  fully  (li'>cril.n.'d  lierc,  tmt  they  must  In-  learned 
pri'  III  :illy  Till'  liireiti'ins  an-  carefully  ttati'ii  by  A.  Kraiikil.  lifrUn.  klin.  ICucA., 
I>^'i7  Nn  II,  rinil  liy  Stern,  fVntralhl.  f.  imi.  M.,1  .  Imh;,  N'.i.  He  The  latti'r  elitaiiicd 
i-siieelHlly  ill  lieate  r"'.=iilt«.  whiell,  li.iwiver,  .in-  imt  iiii-i>-ary  fur  rlinieal  jinrpiisi'-  with 
the  nil!  of  tile  I'lijiillarv  jiippt  of  (iiiwrs.      It  iiui\  In-  inriili.ini-il   liere  that  i|uiti'  iieru- 

rule   ri-nh-.  i|niti'  Mitlieifiitlv  so  fur  elinieal    piirp'-i.-,  ni!i\   1 limiiied  by  the  u f 

siniill  i:l:i--  I'Mpilbiry  pip"!-,  iiianufiictureil  bv  clr;iuin^  nut  -ncill  pieece  ef  erdinury 
!;Im--  tuliiiiLT  in  till'  lliinie  One  or  ninr.  ilrnp*  ef  '.In'  -iTiim  un-  ilmpin-d  I'mni  lUn- ef 
the-e  pipet-  into  •(  di-le  Mild  tin'ii  fmiu  tlu'  -iiiin'  pipet  n  sutlii  iiiit  iiuniher  nf  drop-  nf 
>|iTiIp  water  nr  -nil  -nlulinn  ;iri'  mldi  d  tn  make  a  dilulinii  ..f  nin-iuilf  tlio  rc'.|Uired 
,],...r,.e.  If,  tlien,  with  the  plnrniuui  knp  one  drn))  ef  thi«  mixture  he  aiMi  d  tn  .me 
•  Imp  nf  ihe  linuillnn-eiilnire  elilained  with   the  -ami'  jil.-ilinuni    Innp,  a  i|niir  aeeiirate 

dilution  i-  nlitaim-d       Tlii-  iiieilmd  h»<  1 ii  iu  n-e  at  the  .ln|iii<  IlnpUiiii  lln^pital  and 

has  provi'd  inite  sali-fmlnry.      The  nllnr  iin'thnd-,  a-  will  a-  a  emiiplete  diMUi<.-inri  nf 

the  wle.le  pmrednre  and  i  rf-view  nf  the   litirature.  Iuim'   I ii   ^'iveii   by  ( 'abnt  in  his 

been.   Th'   ,"^i'nim-iiia'_'nn-i..  of  Di.-ea-e    ' 

'  r.,-  i-ir  ■'  /.. .-  rit.  '  /<■'/  f.  Hvn.  u.  inf.u'n.n^i.  .  xx'.'i.  Iiifts, 

^  Miinrli.  n,'./     If,.-/,      lsii7    >;,,    ,-,  •  /iVv/ni.  A/ni,    H'..<-/i.,  IxnT.   Nn    li;. 

'  /Vl,^v/,  ,„r,r  \i:,rh  ,  iny7,  No.  15,       "  iu,-hn.  hh».  ir.i.-/e,  i«i7,  No.  n. 


yi/.i',  Vis7> 


J -J!) 


,i,,„ 1  ;.;(HH(   ,„■    .MMin.    aii.l    111    M    '"i t'    NVi.liil'-,   -v.  I,     1   :JtMH.H. 

r,,i-  .rm'.:il    |.Mi|....,>   -II.  I,   ,liliiti..ii>  .iir  uli..lls    miii.'.M.>.-Min.      <  i.ii.r- 

,llv,    1    ,■ ill,.    lMV-.ll-    !..    .liliiti.Mi-    ..!■    rn.,M     I  -..id    tu    1  :l<.n.    ;„i.l 

:,tl".l'  Ml.iM..l:uit  ,A|„Tir,i,-,     1   U^^        ..  n    na-..„  ,,.  1.,.  sili-ll.-l   tlirivunl,. 

N.A.illirl.  — ,   1    li:ivr    Ir,  .|U.iitly  -..11    til.'    iv;irii •,iir  uilli  .liliilicli^ 

,,|-   ,V,,Mi     I    :    Ii"i    I..     1    :  'i'"'    :Hi'l    ^i'-''^.',    .■t'U'H    '  •^ '  "    "I""    'I"'    '■'•l''""' 

,„.,.,„■.  uiiliiii  a  -li-f  t.ui..     Til.'  time  elapsinK  before  the  reac- 
tion occurs,  :i-    iii-t    iii.iili..ii..i,  i-   Mil  .'.iimIIv    iiiil".rlMnl  ta.'l.ir  in  lli.' 

,li:,^M...-ti,'  .ni,.l..M'ii.Ml  ..I'  -l,.-   nai.i.iM.        TIl     -li'irl.T   ti,.'  a.-ti '  tl,,. 

-.i-iM.i,  i.i   ..nl.r   I.,   .jlitai.i  a  r,,in|,l.l,     na.-liMii,  ll,.'   lu-iv   .•.rli.iM   is  llu' 
,lia-ii.)-i-^,  <-vi'il    wIk'Ii    1m\\    .Iliuti..ii-   aiv    riii|.l..\ .  .1. 

A-  a  iv-iill  ..f  ill.-  t'-r.p.iiiir,  ill.'  prill. 'il'l'-  li:i-  III  'I"'  <'"iii'-<'  "f  <i""' 
,l,.vr|..|..'.l  ill  til.-  .'lilii.':il  a,.,  H.'allni,  ..r  ill.'  in.'lli.i.l  "l'  .li-l"'ii-iMt: 
uilli  lii-li'i-  .liluti.iii-.  Mini  .l.'iiian.liii-  iii-I.'a.l  i.r..|".rli..nat.|v  irivatcr 
mi.i.lily  ill  III.'  ..n-.'t  ..f  tli.'  iva.'ii..ii.  If.  a-  lia|.|..ii-  -•  iV..|ii,iitly, 
<■.— ali.iii  ..f  iiL.tilily  aii.l  aL'«iv.,'ali..ii  in  iliinii.-  laU.'  |>la.'.'  willi  li^'lil- 
niiifr-liU,.  ra|M.lily  ..n  a.l.lition  ..f  lliu  .inin,  a  .liairn-.-i-  .if  tyi.li.>i.l 
I'cv.i-  inav  !>.■  ina.l.'  uitli  iiu-At  |>r.il)aliilily  wli.'ii  .liliiiii.n-  .if  1  -.-'.^K 
oft.ri  fv.n  xvith  .liliili..n-  .'f  1  : -",  ^r.'  .•nii.l..yo.l.  Willi  <iilnli..n-  "\' 
I'l,,,,,  1  :  ID  t..  1  :  .'lit  .'IT..!-  will,  a.'.'..nlin^;  U>  n  v  ,\i..ri.'n.-»'.  lai.  ly  Ix- 
.•..iniiiittP.l.  SI1..11I.I  111.'  r.'a.'li.m  ii..t  ...'.ni'  al  ..n.'.'  with  mi.-Ii  .liliui..ii-. 
tl„'  ..Iwrvati.m  -li.ml.l  I"'  .'..minn.'.l  f..i'  a  IciiL-.r  lini.',  ami.  with  a  \  i.'W 
t..  gri'ai.T  .•.Ttainiy,  wiili  tlio  fiinliur  a.l.liti.Mi  ..f  m fum  O.-mt  .l.'grws 
(if  ililiiti.iii). 

Ill  Ills  ii.hniialil.-  ]>!^»t  u|«mi  ili.-  ^.mr.'cs  i.f  error  in  serum-diagnosis 


Stern'  siwrfesls  a  .'.intinuatiDn  .>!   the   uiist-rvalioii 


f'lr  a.H  IciiiL'  its  two  li.uirs. 


with  |,r...'ressiv.'lv  incrcasin-  .liluli.ms.  Althons-h  tins  lias  yulilnl  hini  im- 
portant r.'.-*ulls.  -ii.'h  a  ihtIo.I  of  oh^Tvation  i.s  iiccor.linL'  to  onr  fxperi-'nce. 
110  lon.'i-r  lUM'.-sarv  f.ir  .■liiii.'al  i.nrp.is.s,  in  vi.-w  ..f  ihf  i.r(wnl  nietli.xls 
an.l  the  skill  iiMiaU'v  j « ».-i's-^'.  1  hv  tlu-  oh^^.Tv.'rs.  In  my  .'linw  our  ohservn- 
tions  do  not.  :is  a  nil.'.  .'XtenJ  liey.in.l  from  iift.'tn  to  thirty  minutes,  an.l 
thev  are  ma.le.  as  s.'.'ins  \<>  me  quite  suffirient.  al  ro.iin-lemi.eraluri.  1  liat 
the"  proeeihire..!  Sn^rn  may  he  .Miiiilov.'.!  in  ea^s  in  uhi.'h  a  .lei'isi.m  is  ot 
esiie.'ial  importan.'f  is  a  mall.-r  .if  eoi.rs.'. 

It  s,.,.|ns  .|iiit.'  imiMii'laiit  thai  s.mie  .IctiiMt.'  riih'  1«'  made  in  r.'.j-anl 
t..  .liluti.iii  an.l  lini.'  limit  whi.'h  slioiil.i  k.'ep  in  vi  w  the  wi.le-t  i>.'-i- 
l)le  apiiiieati.iii  "f  th.'  m.-th  ■.!  t-i  .'lini.'al  imri.. -e-  ami  y.'t  eairfnllv 
jruanl  apiin-t  .iT.n-s.  F.ir  several  years  at  th<  .I"hii-  H.ij'Uins  II. .s- 
pital  a  staiHlanl  ..f  .lilmi.m  .-f  1  :  '>0  an.l  a  iimNimum  tim.'  limit  ..f  .me 
li.mr  have  Imvii  .•m|il..y.'.l  ami  have  ^Mvrii  .'..mplel  ^ali-faelion.  It  w 
re<iiiire.l   thai    e..!!!].!.!.'   a.jLdiitinatioii   I).'   ..litaMii.l   within    tluse    limits, 


430 


rvrnoii)  ri:vi:i!. 


f 


in  oTilvi  iliat  til.,  ivaction  !..■  ccM-idrnMl  poMtiv.'.  Wliilc  will,  tlio-c 
irtandaiM  it  cjiiiir  (■(.nini.Milv  (iccius  that  a  pc-itiv.'  r.^actioii  is  n,,* 
ohtaiiif.l  until  iat.'  in  tli,'  ,iiMa~,',  if.  on  the  utli,.r  haiwl.  tiirv  uviv  made 
itiiy  li—  liL'iW.  rx|M.ri,n(v  ha-  -Ik.vmi  tiiat  'Kcasinnallv  a  jto-itivr  r.MiI. 
woislil  lie  (ilitaintd  in  I'a-t-  nni  tv|v||i,i,i. 

Amoni:  ihr  -,,niv(-  ofcrnir  in  >cruni-uiaf.rnn>is,  tlic  iniiH,rtaiit  oIixt- 
vatinn  .-lionld.  in  conclusi.in,  I,..  .M.nsi.Kivd  tjiat  tli,.  ajx^dutiiiatinf,' 
action  ofthr  -fiinn  may  |Mi>i>t  ti.r  niontii.  and  cvi'n  years  af't.T  nr.iv- 
f.-y  Inini  tlir  attack  of  typiioid  i;.vcr  (l.icliliicini,  C."  Ffiiidvcl,  Stcfn). 
A-  a  iv-ult.  it  ini-lu  hapiicn  that  in  tiic  ca-c  of  a  patient  not  sntl'crint; 
tVoni    tyjihoid    llxcr.    l,ut    cxIiihiiinL^    fever   fmin    -ome  otli.T  eaiise,  the 

(Jrnhcr-W  i,|:d    ivacti eenn-inir   in    c'>n-ec|n.nce  of  an   anteceih'nt  hnt 

not  e\i-tent  attack  of  i^pjioid  fever  nii-lit  lead  to  error.  The  po--ihK' 
•  leleiice  that  tile  jii-iory  wonM  atllifd  protection  from  sueli  an  error  is 
invalidated  l.y  tli..  i;„t  that  mild  ca<cs  of  typhoid  fever  which  viel.l  the 
i-e:i(  tion  c,|ually  uiiii  -evere  ca-e-,  not  ranly  rem, .in  <loiil)tfnl  or  wlioilv 
lilllecoi;ni/e<i. 

ProRnostic  Significance.— Finally,  an  cfTort  ha-  i.e.n  made  to  aserihe 
to  ihc  -eriii.i-reactinn  a  pni-iinsli<>.  as  well  as  a  diairneslic,  importance,  inas- 
nnicli  n>  Catnn'  h.^lievcd  that  he  ohs.-rved  a  direct  n-lalinnship  hetween 
the  rapiditv  an.!  tli,.  intensity  of  the  Wi.lal  leaclion  and  the  severity  nf  the 
individual  •■a-c.  This  statement  has  already  heen  c.inlradicted  hy  Stern, 
>Mlh  whom  1  am  dispn-e.l  n,  a-rce  a.-  a  r.^sult'of  per.-^onal  experience. 
'  .V//.,  „„,(.,  Is'.m;,  N,,.  lij. 


■  |-^'- 


H 


IV.   THE    PROPHYLAXIS   OF  THE    DISEASE. 

Tin:  iiifa.-iircs  t'nr  the  jncvi'iition  of  the  .Um'um'  iii:iy  ho  divided  into 

tlircf  iiiiiiii  i:n)U|).-  -. 

1.  (ipiicral,  wliirli  arc  dir.'.'tc<l  to  tlic  protection  of  tlie  inhabitants 
of  entire  (hstriets,  citio,  or  h->  cxten>ive  collection-  of  .Iwelliii--,  against 
the  di-ease;   or.  if  it  has  developed,  to  prevent  its  di^,-.eminatio^. 

■J.  Special  individual  measures,  hy  means  of  which  the  imniediat<-  or 
me-liate  tran^mi-.^ion  of  tyjihoid  f.'ver  to  tho,  .■  who  come  in  contact 
with  the  patient,  or  even  to  reinot.'  distances,  i>  prevented. 

;5.  I'reventive  inoculation,  hy  ineaii>  of  which  an  attcmjit  is  made 
to  render  the  person  inoculated  immune  to  the  di>ea>e. 

F.,r  the  priniMpie-.  underlyinir  iiie  foUowinir  statemein-  reference 
should  he  mad.'  to  tlie  chapt<T  on  Klioh.jry,  and  particularly  to  the  con- 
cludint;  sentence-  thereof  (p|).  77,  7S). 

GENERAL    ME/  ■  JRES. 

By  reas.in  of  the  uhi-iuily  of  typhoid  fever,  the  persistence  of  it.s 
oxeitiui,'  airont,  and  the  character  and  tlie  activity  of  intercourse  at  the 
present  dav,  tlie  dan>rer  of  the  di-endnatiou  of  the  disease  hy  the  -^iek 
or  hv  intermciiary  aj.'ent>.  especially  infected  art icle— beverages,  arti- 
cles of  foot!,  liiwn  articles  of  clothing,  etc. — cannot  wholly  be  pre- 
vented. In  almost  all  iilaces  of  coiisi.hTable  size,  even  in  those  with 
the  'le-t  sanitary  administration,  the  disease,  at  h  a-t  with  regard  to 
individual,  nndouhtedly  in  part  import.^d.  instances,  never  becomes 
wholly  extinct.  In  view  of  the  impossibility  of  preventing  thi-,  tho 
prinei|)al  effort  of  iiiiblic  sanitation  <hould  be  directed,  by  means  ot 
inte]liL'<>nt  and  adequate  iiie;isures,  to  the  re-trictiou  of  the  preservation 
and   disseniinatioM  of  the  exi'iting   agent    cmanatitiir   from  the   |)atient. 

REGULATIONS  OF  THE  SEWAGE-CONDITIONS. 

Bv  far  the  most  important  general  niea-ure  is  the  approjiriate  n<jrn- 
lation  of  the  sewau'c-conditioiis  and  the  provision  of  a  hygienica'lv 
nnobiectiouable  and  abundant  water-^niijily.  Tiiat  public  .attention 
.^iliouhl  also  be  given  to  the  maintenance-  of  the  greatest  possible  doirree 
of  salubritv  of  the  dwellings  and  their  snrroiunling-:,  as  well  as  hygi- 
enic supervision  of  ilie  conimiinity  in  general,  is  a  matter  of  course,  and 
will  be  referred  to  in  detail  -ubse(pieiitly. 


ill 


■il! 


^■y.: 


■i.iii  TYi'iinin  ii:vi:n. 

Till'  ninoval  cf  rcl'ii~c  tnnii  iiili:iliiirc|  |il:i  -  ii.  vi  w,  in  arcunl- 

aiicc  wiili  |in-(Mit  ciiiiccptinn*  licariiiir  "H  t'"'  'vvcnti^  I'l'  ty|iliiii<l 
i'cvcr,  tlic  ci  rtaiii  niimval  d'  tlir  l'itiii-  dcrivctl  :  ...  \\\\-  A  |iati<irts. 
Mild  \\\\\<  li  r  wiilidniwal  tVdiii  ■iiiy  dinil  or  •i.lirp"-  iiitliU'iicc  upini 
licaliliv  |i.T-on-.  Ill  a<ldiii(iii  t(p  tlic  nriiic  and  I!.  lools.  rcliiM'  water 
(spcciallv  is  to  lie  taUtii  into  f(iii-idri'aiiiiii  in  tlii-  cdimk  ion.  ..IxiVf 
all  (itli<  r  tiiiiii:-,  'arc  -licudd  he  taken  tliat  mme  nl'  tlie-e  are  |periiiiiled 
to  remain  in  Kadiv  devi>e<l,  |Krvion>  ee— |hi(.1-  and  dniiir-pils  ii'  'lie 
neiiilil)iirhi>od  ci'  liiMiian  lial)itatiiin>,  or  i-  <  i  nveved  to  ailjaeeiit  nnii.-e<l 
land  ir  ^^aiii:-  eiitraiKe  into  trnlter-,  oi-  even  into  water-ways  wliicli  serve 
direetlv  a-  a  -oinve  ol'  the  water  n>e<l  hy  tlie  eoniinunity  lor  drinking 
and  tor  doinotie  |iiir|io-e-. 

In  acconlanieuilli  the  r-'v/x-  and  partienlar  ceiiditioiis  <if  a  eity.  the  arraiipe- 
meiits  I'lir  the  drainaL'e  Hiay  he  variahle.  While  thi?  can  ;rentTally  he 
w'cnre<l  ill  larL'e  cities  only  hy  iiieaiis  of  aippropriate  tlush-sewers  with  irri- 
jratinL'  tields.  less  coimnonly  hy  coiivevaiice  into  hirt'c  water-courseis.  for 
(iiiialhr  and  the  Muallest  cities  the  |irovisioii  of  a  comhination  of  removal 
and  tlushiiiL'  svstenis  :se]iaralion  of  the  solid  and  liquid  refuse  matters  and 
removal  in  various  wavs  i,  or  even  the  imi-system  or  the  i)it-syslem,  will  he 
entirely  adeiniate.  • 

WATER-SUPPLY. 

Almost  :-till  more  iini)ortant,  in  coniliinatioti  with  the  system  of 
sewai^fe  adapted  to  the  local  conditions,  is  the  provision  ot'  an  ahiui- 
daiit  siipplv  of  niiohjectionaMc  water.  it  ha-  already  lieen  seen  that 
water,  in  the  various  forms  in  which  it  is  employed — as  drinkinir- 
water,  a-  an  addition  to  artii'lcs  *'{'  food  and  lieverac;es.  ami  a<  ii-ed  l()r 
elcaii-ini:  ]iiii|io~c-  on  a  laiire  scah — coiistitiiles  hy  far  the  most  common 
medium  for  the  d!--emination  of  the  disease  wliiih  needs  to  he  taken 
iiiti)  coiisiilcration.  <  >f  how  little  service  even  the  hc^t  system  of  drain- 
aL'c  and  -cwaL-'c  and  the  re-nltiiii:  ])nrifieatioii  of  the  soil  m,;y  he.  when 
it  i-  associated  with  an  nn-iiital>le  and  directly  injiirioiis  water-sii|  ply, 
ha-    hecn     diown    l.y    the    events    at     Hamhiifi:    previoii,-.ly    mentioned 

(l;)..     II.     lo). 

An  im])ortanl  r,,|iiircmeiit  of  .a  ri'ally  c-ood  watcr-serviee  is  an  imiii- 
tcrrupicd  -iipplv.  ill  -uch  ahnndancc  that  if  i«»sil.le  a  distinction 
need  not  he  made  Im  twecn  drinkinL-'-watcr  and  hss  reliahle  water  for 
domestic  pnrpo-c-.  A  par  from  the  fact  that  ahundant  op|.ortnnity  for 
infection  i-  atl'oid.<l  ihron-h  water  used  for  dome-tic  pnrpose- (clean.sinfr, 
rin-inL^  wa-hiiej.  and  l.aihin-),  the  prevention  of  its  us<.  for  drinking 
pnrp,,s,.s  ajiii.'MV-  practically  entirely  illii-orv.  in  the  determination  (d' 
the  chara.'ter  of  s\:\u\-  from  an  I'pidemiohric  st;indj.oiiit.  liiologic  exam- 
ination   is   of  LM-eat   direct,  and   cliemic   examination   of  rather  indirect, 


rniipiiYi.Axis. 


i:].'. 


sijriiiti<';incc.  Tlic  \MU-r  iiinii>li.'s  tlic  .luniic  \y.\>y  for  the  susi.icion  of 
•ii-irani.'  .ontJimiiKitioii,  wliilc  l)y  mcuii^  of  tlic  lornicr  tliu  (.n.-ciuc  of 
!.;wi,ria  in  ^.'runil  in  tiic  wiitir  is  t-t:il.lir-li(<l,  ;iimI  cvou  at  tinifs  tlit- 
(icnionstralion   nl'  f.  |iiioi(l-li;uilii   ran   l>c  (linctiy  made. 

Ill  „nlrr  to  i.n.vi.lf  an  JrrciproacliaM.' Mipj^lv  of  water  for  .Irinkiiiu;  and 
•  lomoslic  |.iu-po>rs  it  will  !»■  iK.-o-arv,  in  caM^  it  ^liall  lie  ol.laiiUMl  from  wtlls, 
that  tlic  i-vravatioii  ^hall  l.c  MiHicitiitlv  .I.mi,.  and  that  the  walls,  i.articiilarly 
in  llu'  upinT  portions,  shall  he  r.-ndcn-d  inipcrvi.>iis  n.  the  entrance  of  infccto.l 
water  from  tlic  upper  layers  of  the  adjacent  soil  hy  means  of  !»nital)le  masonry 

and  ivnientiiiL'.  ,  ,      .  , 

Tlie  water  derived  fn.ni  sprie.L'S— of  tis  de.'l>  a  sonive  as  pos.silile— slionit 
lie  c.invcved  throu-h  iinpcrvious  tnhes  ilircctly  to  the  l^lace  where  it  is  u-cd 
with  all  "prai'licahle  avoi, lance  of  contact  with  the  external  world.  Kspenal 
care  should  he  directed  to  the  certainty  (.f  iinpervioi:sness  of  the  coiiduils 
for  spriiiL'-water,  from  the  propln  hu  tic  .-taiidpoii.t,  and- luitnrally,  also,  m 
coiiuection  with  epidemiologic  investi-ation.s.  Water  that  is  primarily  the 
hc-t.  if  li.il  ade(piatcly  protecte.l  in  the  course  of  il>  distrilmtion.  may  lieconie 
a  source  of  ilan^'er  owiiiL'  to  contaniii.i'tion  from  its  stirroiintlin^'s— pits, 
infected  superti<-ial  layers  of  soil,  .lirect  commu:\'<'ation  with  cesspools,  admix- 
ture of  rain-water  and  nielte.l  ice  and  snow,  and  all  other  possilile  sources 
of  accidental  contamination.  The  history  of  lyjihoid  fever  exliihits  a  larire 
nuniher   of  smaller    and    lar;;er    epi.leinics   develoi.e<l   in    this   manner  ( (ip. 

4-_',  4:?^. 

When  the  water-supjilv  of  a  place  must  lie  ohtanied  trom  open  water- 
ways, rivers,  hrooks.  or  from  seas  and  ponds,  the  water,  before  lieini,'  a<lmitted 
iiill)  the  dwelliuL's,  should  he,  in  its  entirety,  sidijected  to  trustworthy  proc- 
esses of  liltration  that  can  he  constantly  controlled  hioloirically  and  chem- 
ically. The  introduction  of  unliltercd  water  into  cities,  with  dci'-ndence 
up)n  suhseipicnt  sterilization  in  the  houses,  is  absolutely  untrustworthy,  as 
numerous  examples,  especially  a'.'ain  that  of  Hamhuri:.  have  shown.  It 
has  alreadv  been  seen  how  uncertain  and  serious  may  become  the  ipi-stion 
of  house-ti iters,  ami  how  ihey  ii.it  rarely  are  actually  a  cause  for  further 
pollution  of  the  water.  If  the  us.'  of  suspecli'd  water  is  absolutely  not  to  he 
avohled,  boiliinr  ami  prcservati.in  in  clean  vessels  sh.iul.l  be  practise.h  This 
applies  not  onlv  t.i  .Irinkiii'.'-water,  but  t.i  all  water  emphiyed,  particularly 
that  used  for  rinsini:,  balhiuir.  ami  washiiiL'.  The  u.-e  of  artiticial  mineral 
waters  in  suspii'ions  places  aii.l  in  times  of  epidemic  will  be  scrviccidile  only 
when  there  is  certainty  that  they  have  been  prepare.!  from  sn-rile  water. 
au'l  that  tliorcniLrh  cleansing  of  the  bottles  has  been  jiractiseil.  fhat  the 
addition  to  infe.'te.i  water  of  tea.  coffee,  or  ah'.dioli.'  beve'aL'es  in  onliiiarv 
amount  cannot  imiteriallv  improvi'  matters  has  loni:  been  known.  Tyjihoid- 
bacilli  mav  retain  their  vitality  even  in  ice.  as  has  been  pointe.l  out.  for  a 
consi.lcnilile  lenjrth  of  time — a  .■ir.'umstan.'e  thttt  is  well  calciilate.l  t.i  enjoin 
caution  in  the  emphiyment  of  ii'c. 

The  def,rrec  t.>  wiiich  tlie  luvvalenee  of  typlioid  fever  may  be  les- 
seneil  l)v  proper  draitiairc  and  a  suitable  water-siipjiiy  wa.x  sliown  first 
liv  the  experiences  iti  I-"nt:laii(l,  t.i  wliicli  were  soon  adde(l  th.ise  of 
France  ami  (ierinany.  In  (b-rnian  cities  tiiat  formerly  siitl.fed  seriously 
from   tvplioid    fever — for    insUiuce.   Municli — the    disea.so    has    at    the 


te 


:?-■*■ 


lYi'iinin  I  i:vi  i:. 


jircMiii  iImv  Mltiin-t  wliolly  <iis;i|>|iv:in'<l.  Tlic  innniiniis  iiilhiciiro 
(•.\crl<tl  ("ix'txillv  li\  A  l;<"'<1  \v:iiiT-sii|i]ily  li;i>  li.'cii  ilciiu .ii>tr:i!f<l  in 
l-'ramv  l>v  \\u-  f\|ic  ritiK-r-  u  itli  ivLMnl  Inllit'  iiMH-tality  tVoin  t  yiilioiil 
l"c\cr  ill  llic  army  iitMl  in  llic  civil  |i..iiiiintinii.'  'V^.r  iiio-I  I'diiviiiriiig 
example  ill  (icrinany  i~  tiirni^lu'd  aj^'ain  liy  Hainliuiy  (^cc  p.  \^>). 

FOOD  AS  A  SOURCE  OF  INFECTION. 
That,  ill  ailililimi  I.>  tlir  wati-r.  mn.-l  <arct'iil  allmtion  -liould  he 
given  esjieeiallv  to  tliiiil<  em|>lnye<l  a-  I'c"!  will  lie  evidelil  Ipiii  ]>revi()iis 
.-tatemeiits.  'I'lie  tir-t  plaee  in  llii-  cdnnec'tinn  i-  oeeupieil  hy  milk, 
wiiieli,  as  iniinennH  exact  in\e-liL;atii>n>  liave  >lin\\n,  may  !«■  a  -luree 
(if  infection  from  intentional  oi-  aceiilental  addition  of  inticled  water. 
Al.-o,  the  articles  of  food  derivid  from  it — linlter,  clieoe,  w  liey,  etc. — 
liave  properlv  reeeiv.d  i:rcat  attention  recently  from  the  |iro|ihy lactic 
standpoint.  1  low  readily -till  other  article-  of  food,  cspi'cially  if  eaten  in 
an  nneo<il<ed  >tatc,  -iich  a-  fruit,  -alad.  elc.  may  he  inllM'led  iiy  the  con- 
taminated hanil-  ot'  the  di-pen-cr.  !iy  riii-inir  and  -prinkliiii.'-  with  water 
eontai'iiiiir  i:erms,  ami  hy  other  manipnlation-.  will  rei|nire  no  hirther 
elalMiratloii.  Sanitarv  otVueis  shonld.  far  tnoic  than  they  have  done  in 
the  |iar-t.  ilcvotc  attention  lo  the  commercial  pnr.-nit,-  involved  in  this 
eonneetion,  ^neh  as  dairi.v-,  n-laurants,  fruit— tore-,  etc.  To  adopt 
])roi>livlaetie  measures  in  tlii-  conne<tion.  'nd  to  iii<|uire  into  details, 
:ip|)car  to  me  far  more  important  than  the  ^till  (piite  cu.-toinary  fruitless 
♦'xaminatioiis  of  soil  and  irronnd-water. 

PROPHYLAXIS  WITH   RELATION   TO  THE  INDIVIDUAL. 

In  this  connection  those  mea.-nre-  should  he  ."ai-idered  through 
which  the  dissemination  .if  th«'  developed  di-ease  tVom  the  ]):itients  to 
those  l)v  whom  thev  are  surrounded,  and  from  the^e  to  niore  remote 
per-on-,  i-  to  he  prevented.  The  uiiderlyinir  jirinciple  of  the  nicasuie^ 
in  (piesticn  may  he  cNprc-sed  in  two  sentence-  : 

1.   The  oidv  infci'tive  .airent  consi-t-  in  tln'  ty])hoid-l)acilli  which  are 

reprod 1    t>y  the   patient   and  are   txtruded   es]iecially  with  the   stools 

anil  urine. 

■1.  Kc-idenee  in  the  immediati'  neiglihorlioo'l  of  the  patient,  in  the 
same  hoii<>',  or  upon  tlie  -ame  th.or  and  soil,  i-.  in  il-elf  :.h-ohil(ly 
iuno.aious  even    f  .r     preili-po-ed    peivon-.    if    it     is     po-il.le   to   protect 

them    from  the   ingc-tion  of  ha.alli.  w  hich  taUc-^    yV l>y  fir  the  mo-t 

fre(|Uentlv  in  contaminate*!  t'ood  and  hexcraire-. 

It   therefo'-e  follows  that   |)atienl-  are  to  lie  so  taken   care  of  an<l 

'  Scf  ('liamiMiic-sc.  .\liil,,'uinnltyjihn^.  p.  7.S7. 


rUni'llYLAMS. 


■\.\-i 


llicir  (ii-cli:ir'_''''>  ;irr  lu  he  ^M  iniitcil  ili:it  llic\  -liall  imi  he  a  snincc  nf 
iiijiifv  111  Mihcr-.      'I'll.'  |iatii'iils  -liniilil,  -d  llir  a-  |ii'acliral)lc,  Im'  rciiioVfii 

I'll  111  Cluwilril  ilwi'llili:;-  :mi|  iViiIll  >lllTi  illllllilHi-  lliat  ill  lint  ]irl'lllit  iil' 
slli-l'acliirv  i-iilatiiill  tVnni  lliuse  alinllt  lliclii.  .iliil  tllr\-  -limilil  he  ~riit  tu 
ilir  liii-|)ital-.  Sliiiu!,!  Jifv  I'ciiiain  in  ])i'ivair  (l«iHiiiL''~,  a  iiiiiiilirr  nf 
iiica-iirc-  that  wniilil  lir  iiiaitcrs  nf  tnur-c  in  a  liii~|iilal  -iioulil  lie  riuidiv 
|iiir-iic(l,  liut   uitli  a|i|irii|)iiatc  niii<iilicatiiiii>. 

Treatment  at  Home. — In  tivatnunt  at  limin'  «w  <>{'  the  es>cn- 
lial  |iiiiui|)l(-  (■iin<i--i-  ill  tlic  provision  of  nurses  and  assistants 

-iilliriclitiy  inliiriiicil  witii  fcuanl  to  tlic  cliarartcr  nf  the  int'cctinii  and 
its  niiidi'  lit'  ])i'cvrntiiin.  liiu-c  wim  dn  iinl  a---i^t  in  tlic  cai'o  ut'  tlu" 
patient  ai'i'  to  In'  rcinn\i'(l  I'roin  iii-  \  icinily.  nr  at  nin-t  iiiii~t  he  |ici- 
liiiltcd  til  Ih'  prr-fiit  till'  -liiirl  \  i-il-  nldv,  a\iiidin;j;  dinrt  ciiiitact  willi 
the  ])aticnt.  'I'lic  niir-rs  and  attendants  inii't  liear  ~erii|iiiiiin>ly  in  mind 
the  fact  tliat  tiie  |iiii--iiii  enntaiiied  in  the  di^eliai'ire-  ut'  tiie  [latieiit  inav 
till'  a  ciinsideralile  time  adliefe  in  an  aetive  -tate  tu  all  |iii--ilile  artiele-, 
I'fiin  wliieli  it  niav  lie  tran-niitted  l.rielh  nr  lie  eniiveved  tnr  Lrreat  di-- 
tanee-.  It  i~  nut  le--  ini|iiii-iaiit  t'nr  tlieiii  in  kimw  that  patients  witli 
mild  ail''  aiiiliii'atnry  attaek-,  a^  "cll  as  healthy  |ier-iiii^,  may,  under 
certain  eireiim-'tanees.  aet  as  the  carriers  and  dis-eminatdi's  nt' the  \  ifiis. 

Of  the  iiiniv  inipnrtant  tietails,  the  arrangement  of  the  sick- 
room may  especially  Ix'  retii-red  to.  It  ^liniild  imt  he  inn  small,  -Imiild 
lie  sn-ccptilile  lit'  ventilatinii,  and  -itiiated  -n  that  a-  miieli  ipiiet  as  pnssi- 
lile  can  lie  secured.  I  nneeessary  articles  -hiiiild  lie  remnved,  and  this 
applie-'  e~peeiallv  to  ronj^li  woiilleii  article-,  (diiiiter|iaiies,  ear|iets,  and 
iiphnNtered  t'iiriiitiir<>.  In  addition  to  the  -ick-hed  proper,  a  second 
bed,  it'  |)iissil)le,  slionld    Im'   in    rea<iiness   for   c'han^'e. 

Disinfection  of  the  Stools. — The  deiections  of  tlic  patient, 
es]iecially  the  stools,  are  iiest  reeei\(d  in  porcelain  lied-|ians  or  i;la>s 
ve-sei>  ( wiiicii,  in  the  liosjiital,  should  he  reserved  tor  tiiis  jiarticnlar 
piir|>ose).  Heforc  lieiiifX  thrown  into  the  watei-eln-ei,  ihoroiitrh  disin- 
Icetiiin,    preteralilv  with     milk   of  lime,   -hoiild    lie   practisc<l. 

This  is  til  he  preferred  to  all  otlier  ilisiiil'eetaiits  nil  aeeount  of  its  cheap 
ness.  Certainty,  ease  nf  a|iplii'ati(in.  and  convenience  to  the  atleinlaiits  and 
llie  family.  In  iletail.  care  sliniilil  he  taken  tiiat  the  Ik  ttom  of  the  iied- 
paii  he  covered  -.villi  milk  of  lime  liefore  each  evacuation,  and  that  after 
the  liowels  have  iiioveil.  the  stonl  he  thoroiiL'hlv  adniixed  with  an  einia! 
aiiiiiiml  of  milk  of  lime.  In  liospiial.s  pn.viiled  with  a  ltoikI  svstein  ••(  tlushinir 
anil  draiiiatre  the  (Itjeetioiis  thus  treated  may  he  thrown  at  once  into  the 
closet,  while  in  private  practice  it  is  advisalile  to  permit  the  ailmi.vtiire  first 
to  stand  for  an  hour.  In  addiiion.  riirorous  smjiervision  and  ilisiiifection  of 
the  closet  itself  are  necessary.  The  seat,  the  hasin,  and  the  jiipes  sliuuld  he 
treated  dailv  with   milk  of  lime,  and  similar  care  should  he  devoted   to  the 


f-,- 


M- 


-i:;t; 


■jyriiniii  I  i:\i:i:. 


i*'^-=^     -^.       -ii 


Pi     I 


tl.M.r.  When,  u\>\vm\  .>f:i  tlii-liiu- -\.-Ii  ni.  lliciv  i-  ;i  i  uriM  Mi-iii  or  pit-MStcni, 
.li>iiit;rii(Hi  uflli.'  .•onl.iii^..llli.'  |>h  i-  ;il-n  iinv.vsir>-lla'  udditioii  daily  oi' 
tVt.iu  ItMi  In  I"'"  'jniin-  nl'  rnilki'l  linir  r..ri'arli  iiidisidual  liciiiL' consuKaM: 
Mitii.'ii'iit.  'I'lial  lh..r.,iiL'ii  rin^iii-  and  .Iran-in- <>f  ^.'d■|.all^  and  L'la.-s  V(•^- 
mI-  -Imuld  Ik  .llrcu-.l  r, -ularlN.  I"--I  uuli  a  -..lulion  '>{'  I_vh>I,  inay  \,v  nm- 
~idrrrd  aluM.M  a^  a  inall.r  ..I  .■niii--c.  In  llii-  rnnnirii,,n  allcnlinn  ^lu)^lld  lie 
-iv.n  f>|H-ciallv  t..  ill.'  .•xurinr  ..t'  ilu'  vr--rl  and  its  lian<llf,  (•(.nla.'t  willi 
uliirh  nii'dil  .It'll. rwiM'  r.a.lilv  r.-ull  in  inf.'.'linu  i.f  lli.'  Iian.ls  (if  llii'  allonil- 
•aiils.  In  a.l.lili.in  L.  inilU  ..f'lnn.'.  rarli-li.-  a<i.l.  and  ly.-.il.  nicivMric  tl.l.n-i.l 
i>  aJMi  aii|ili<"dilf.  .m  a.'.'.innt  nf  ilic  n  lativfly  small  anitniul  .if  iiiiicii!-  and 
alliuniui  .■nntaiiif.l  in  llic  lypli'iid  .Icj.'.ii.ins. 

Til,'  ivlialil.'  a.-li.in  ..I'  milk  nf  liin-  .l.ii.'n.l-  ii|m.m  it>  iimii.r  iiroiiara- 
li,.ii.  It  >linnl.l  li.'  .  in|.l..yc.|  in  a-  liv^ldy  |.|-.  (tared  a  .-tal.'  a~  i.u-ili!.' — 
at  anv  rat<'  imt  afi.  r  it  i-  .d.l.r  lliaii   three  days.      It  is   li.st   l.i  iinjiaro 

til,'   n.'.'.'s-arv   ai mt    .laily,    tli.'   -lakcl   linn-   h.iiiL^   mix.-.l    whh    IV.itii 

iw.)  to  r.mi-  linn  s  tlu'  :..ii..iiiil  td'  waUf.      U  sln^ul.l  tli.ii  I"'  luv-ci-v..!  in 

C'l.i-.'.l    \t's-.U. 

In  Fratu'.'.li.-inr.'.'ti.ir  uilli  <'oii|i.'r  suljilial.-  is  nuicli  i'iii|il<iy,'.l.  oii.rially 
u.mn  llio  ri'.'.ininu'ii.lali.in  <if  Vin.'int,-  Tin-  IWal  diseliar-es  arc  mixed  with 
an  a.le.iuate  aniniiiit  of  a  .'i  I'er  .-.nl.  solution,  to  wliieli,  liesi.l.s,  1  i>er  eent. 
of  suliilmric  a.i.l  is  a.l.le.l.  In  (  i.rmany  tlie  in.tliod  lias  not.  to  my 
kiioul.'.ltre.  I'een  .nii.luyed  upon  an  exUiisive  seal.,  and  1  liuve  no  penHMiul 
ex|H'rien.'e  willi  il. 

Disinfection  of  the  Urine.— Tn  vi.  w  of  tlie  pront  fiv.iueney 
xvitli  whi.'h  tvj.lioi.l-baeilli  are  fouml  in  tlie  mine  of  typli.ii.l  patients, 
often  in  inunen-.'  nMinl..'rs  (s.'e  p.  31),  tlie  extreme  iniportaiiee  of  care- 
ful .li>inf..'ti.in  .if  all  such  urine  wili  he  a ]. parent.  Cxvyn'has  made 
a  canftil  .xp-riniinud  sin.ly  wiili  ref.'nn.-o  to  tlie  Ik'-I  metliods  by 
xvlii.'h  tlii-  ean  I"'  .arri.'.!  .mt.  lie  .'.melu-ies  tliat  milk  of  lime  liardly 
<l,'-erves  tli.'  nam.'  ..fa  .li-iiife.'tant  in  tliis  e<iniieeti.>ii.  Carli.ilie  aei.l  is 
of  us,,  .luly  ill  larir.'  aiimunts  an.l  str.niL'  s..liiti.)ns  if  a  spee.ly  r.-iilt  i- 
ui-li.Ml.  F..rmalin  is  an  ex.'ellent  di-inf.etaut,  liiit  is  t..o  expeiisiv,'. 
r.i.l.l.trid  ..f  nur-Mirv,  ehl.irinate.l  lim.',  an.l  luiui.l  .lil.iri.l.s  are  ..f  real 
vain.',  are  ni.i.l  in  tli.'ir  a.'ti.m.  an.l  ar.^  .'Ili.'i.'nl  in  eotnparatively  dilute 
s,,lntinns.  \h  lia-  fmnd  tliat  f.r  di-inf.'.'ti.m  xvitliiii  live  t..  tiffen 
niimit.-.  one  vnlnmo  of  urine  m.iuI.I  iv.,uir.'  ,,n.-twenlietli  t..  .me-tenth 
of  it-  voliim.'.d"   I  :100(»  H  TL  -nliition. 

Fn  vi.'w  of  111.'  .'X.-.'ll.'nt  ivHilt-  .il,tain.'.l  by  tlie  u^o  of  ur.>tr.ipin  m 
eas,'s  of  tvphoi.l  ba.illuria.  Ki.'lianl-.m  lias  a.lvi-.-d  llie  romin.' admiii- 
i-trati.in  .'.f  tlii-  .IruL'  in  the  latfr  p.'ri.xls  of  tli.'  disea-e  a.s  a  i.revcmive 

.  F.T  p.irnMil:,.'-  unli  n'L'.ra  t..  ,li-inf.'<'t:int-  ami  n,.-tl,...l^  nf  (li-i..f.'Ption.  r.'frr- 
.„,..  „.,.  L  ,„a.l,.  n.  an  urti.l.'  I'V  K.  I'fuhl,  Z-iL /.  Uv;,  u.  I,.f.-I.f:..,.k.,  ii.l.  ^i  .  Ml., 


ri:iii'iiYi..\.\is. 


437 


ami  [.loplivhiiii.'  iiir;i-iiiv.  I'n.haMy  .")-<ri-;iin  .Ium>  ;riv.ii  ilinv  tiiiu's 
a  (lav  aiv  -utliri.ni  \'i<v  ilii-  iiuri>o-(  .  it  -ImiiM  lie  nicniioiicd,  lu.w.  vcr, 
that  -cvci-al  ra-t-  oj'  liriiioo|,,l)iiim-ia  tullowini:  tiic  cimtiliucd  ii-c  i.f  tliis 
(Inij;  lia\i'  l»iii  I'lpi'itrcj. 

Till'  disinfection  of  the  sputum  may  \<v  acci.miili-ti.d  liy  the 
use  of  milk  "i'  limi-  or  -ohitioii-  of  carliolic  ariil  or  ly-ol. 

Ill    :i,|i|iiioii    to   tli<'  M<ntioiis    and    cx.rctloiis  of   the    iiaticnt,   the- 

trrratot   ailciiiioii   -.hoiild  lie  Lnvni    I any  othrr  thing's  that  ic  iu 

rnniart  with  him.     Thii-.  wash-water  and  bathing-water  ami 

ai-o  remnants  of  food  fmm  thr  tyjihoid  patient  shoultl  not  !»■  thrown 
awav  witiioiit  ]ir(\iou- di-infii'iion  with  milk  of  lirnr.  Careful  attend- 
ant- will  of  them-ilve-  -ee  ihal  the  palieMl  i-  |irovi<led  with  .speeial 
plate-,  ni;i— e-,  and  ealinii'  nteii-ii-.  l'>pe<ially  important  is  disinfec- 
tion of  the  bed-linen  and  the  body-linen,  and  any  other  articles 
1)1'  eiotiiin;^  n-ed  liy  the  patient,  a>  well  a-<  hi>  napkins  and  haiid- 
kenhiel's. 

In  Di-der  toavoiil  mnit s.-arv  ihrowiiiL' alioni  and  repeated  manipulation, 

tile  articles  in  .pie.-liou  are  iiesi  kept  in  not  uater-li-hl  )  sacks,  and  tiiesc  in 
tarn  in  p(n-ce]:.in,  eartlu'iiuare.  or  zinc  vessels  that  can  he  clused  and  are 
partlv  tilled  with  a  •>  percent,  sohiticin  of  earholie  acid.  The  linen  thus  nut 
completely  <lisiiifecled  is  lirst  suhjccled  to  sterilization  in  hot  steam  or  hy 
bdiliiiL'  in"sijai)-water.  with  aildition  of  s(jila  or  petrolenm  >  ( !;irtiier),  l)ef(jre 
heinir  iriveii  to  the  laundress,  and  only  then  suhmitted  lo  the  remaining 
pr(ice.sscs  of  ■•  ashintr. 

At  the  termination  of  the  di-ease   the  heds  arc  to  he  thoroiljilily  dis- 

Itifectcd.      W len    hed-teads   are   carefnlly  cleansed  with  a  •">  per  cent. 

solution  of  carbolic  acid  or  lysol,  while  iron  bedsteads  are  treatc<l  by 
steam  sterilization.  Mattresses,  blankets,  and  pillows  also  are  disiii- 
feeted  bv  steam.  When  steam-disinfection  is  n<pt  available,  mattresses 
and  pillows  are  emptied,  and  both  coveritifx  :ind  contents  are  disitife<'tetl 
bv  boilinir.  N'alneless  articles  oi"  bcddinjr — straw-sacks,  husk-pillows, 
etc. — had  better  be  bnrnetl  directly. 

The  bodies  of  those  dead  of  typhoid  fever  arc  by  no  tneans 
,so  (ian<!;erons  with  reirard  to  the  ilisseininatioti  of  the  disease  as  was 
formerly  thoiitjjht  under  the  iidlnencc  of  the  pntrefactive  theory-. 
Cleansinij  and  coverinir  the  buccal,  n.asal,  atid  anal  orifices  with  traiize 
dippeil  in  milk  ot'  lime  or  carbolic  solution  wniild  be  likely  to  sutfici,  as 
a  rule.  If  especial  care  is  to  b(>  cNenised,  particularly  in  the  matter  of 
distant  traiispoilation,  the  ImmIv,  without  pre\  ioiis  washiiiir,  should  be 
onvelope<l  in  ( loths  s;,tiirated  with  carbolic  solution  or  tnilk  of  lime. 

Disinfection  of  the  Sick-room. — Tliat  the  bedriK)m  shoidd 
receive  most  careful  attention  during  and  after  the  attack  is  a  matter  of 


.  i^m'j 


^sC^  Will 


?-."-■ 


4oiS 


rvriioii)  II All:. 


oinirsc.  After  it  li;is  liccn  vacatid  l)y  tlic  <(jii\;ilc«<'<'nt  |iiitifnl,  llic  wall 
:itr:iiri>l  wliiili  lli'  licil  -tuud  -ImiiM  ln'  riililpiil  dowti  with  hnail,  or, 
>liiiiil(l  it.--  ciiMi-in;.'-  Ii>l(nit(  liini.-liiri',  it  -IkiiiIiI  lir  tripled  with  ;i  ."i  iicr 
cent,  -'iliiiimi  (iT  carUi.lir  acid  and  S(ia|).  I'lirniluic  u.~cil  li\  the  patient, 
i'-liceiall_v  tile  lird-li  III  and  cliaif-,  and  iIk'  IIimh-.  -Iiould  lie  disinfected 
in  tile  latter  manner.  It'  thi'  ttiMir  i-  nut  painted,  it  will  lie  Ketter  to 
empliiy  niilk  uf  lime.  The  cnick~  lietween  the  Im.ard^  -Imnld  receive 
particular  attention.  I'hc  di.-iiit'ectiun  ol"  nium^  imt  i)ccn|iied  hv  the 
patient  ami  kept  t'roin  euiitact  with  hi~  dejectinns  i>  nimece--arv.  In 
private  practice,  i.-pcciall\'  under  ciindition>  amid  which  the  inethiid> 
111"  cleari>iiii.'  caniiut  he  .-iilliciently  depended  upon,  it  i~  advisahlc,  .'d'tcr 
emptying  the  roimi,  td  undertake,  hesides,  di>iid'ectinn  witii  tiie  vajxir 
of  fcirinaliii. 

E.-pccially    important     aUo   in    eoniiectiun    with    piopiiylaxi.-   is   the 

maintenance  of  cleanliness  on  the  part  of  the  patient  him- 
self, of  lii.-  skill  ill  f.'eneral,  jiartienlarly  ahoiit  the  month  and  the  .■iniis, 
and  his  hands.  Particular  attention  .~hoiild  lie  direi-tdl  espeeiallv  to  the 
latter.  It'  this  i-  not  done,  the  patient  may  readily  coiivev  iiifcetious 
material  to  various  nteiisiU,  artieli's  of  food,  etc.,  and  thus  hecome  a 
source  of  daiiL'^ef  not  oidv  for  those  imniediatelv  ahoiit  him,  hut  for 
others  at  a  irreater  distance.  The  attendants  must,  for  the  same 
reason,  <levote  the  most  scrnjiuloiis  care  to  their  haii<ls.  I  am  eoii\inc<'d 
that  not  a  few  cases  of  aiito-infectioii  and  of  dissemination  are  attrihu- 
tahle  to  carelessness  in  thi>  connection. 

The  (lisiiifeetioii  of  liie  hands  slioiijd  he  practised  ac<-(irdiiii;  to  the  rules 
ohserve(l  hv  snrL'eons.  namely,  thipnuifrh  wasliiiii:  and  hrushiiiL'  with  snap 
and  water,  followed  by  prolonged  iiiinieision  in  iiiereuric-chlerid  solution, 
giviiiij  pro]¥'r  attention  to  the  nails  and  the  space  heiieath  them.  In 
hosfiitals,  in  this  connection,  too  careful  snjiervision  of  the  nurses,  ])articu- 
larlv   tho.^e   of  :  iiort   experience,   cannot   he  exerci.-ied. 

Further,  physicians  and  nurses  in  attendance  upon  tyjihoiel 
patients  should  lie  provided  with  clotliinj,'  that  can  he  wa.-hed,  aiiii  at 
the  end  of  their  service,  espeeiallv  Ix'fore  {roinjj  to  tiieir  meals,  tliev 
should  clianjre  their  clothiiiL'.  In  hospitals  it  is  advi.sahle,  in  ea.se 
typhoid  patients  are  cared  for  in  the  same  w.ird  :is  others,  to  provide 
hut  one  nurse  for  their  care,  and  to  keep  others,  paiticiilarlv  those  who 
are  concerned  in  hiin^diiir  the  food,  attendin;^  to  the  cleansing  in  p'tieral, 
and  the  care  of  the  remaintler,  as  strictly  as  possil)l(>  apart  from  the 
typhoid  jiatients.  \\'hen  ty[)hoid  fever  occurs  in  hoarding-sehool.ss, 
tiarracks,  jails,  and  institutions  in  jrenenl,  espeeiallv  tlK)se  eontaininp 
yoiinir  persons  in  considenililc  niimher,  immediate  isolation  of  the 
.>.,*;, ......   .„...r..,s.i.i,.  ..,..., 1  f....„,  »i,..  1, : ....»,.       i> i.. .!.,„*:„ 


ri:ni'iiyi.A.\is. 


439 


nwisiires  wotil.l,  imd.r  Midi  ••irciimM:iii.v>,  Im-  ^ll^.■.•l.lilll.■  nl'  ;ip|.li.ati(.u 
olilv  uilli  (lill'uiilly  :iii(l  uii>Trl:iiiil\ . 

Preventive  Inoculation. — In  MiMiii'm  in  the  |m..|iIi\  lu<iic  mcas- 
urc<  ;l".vr  (li-ni-.a,  ulii.li  aim  .-|M.ialU  at  ilic  pn  v.iiliun  of  llic 
fui-.li.T    -I'lva.l    aii.l    .li".liiiiiati.iii    nf   llic    vim-,    tluiv    lia-    lal.  iy  l.,vii 

intn«lii.v.l  a   itua-mv   .lind.-l    t.AvanI   tli.-   piw-liMii f  an   arliti.ial 

iinmmiitv    in    llic    indivitlnal. 

K.,1  lowing'  tlu'  work  of  llatlkinr  in  va.rinalioii  a-aiiist  cli..!.  la, 
Writrlil.  of  Nctlcy,  lia-  introiiu.iil  a  similar  ni.llio,!  of  va.ciiialioii 
a>raiii-t  lyphoi,!.  Tiir  mat. rial  n-d  i.  a  hoiiilLn-.-nltniv  of  Harilliis 
tvpliortus  ..f  liii^li  vinilrn.T,  luat.a  until  all  oi..rani-iii-  aiv  .l.a.l.  Tlu' 
amount  iiiociilalcl  -lioiil.l    ■  !..•  -ii.'li  a  .|naiitiiy  uhic-li.  if  iiij.vt..!  aliv.-, 

would  !..■  fatal  to  a  .'..-.d  t:m.  -nin.a-pifr."      Tlw  i ulatiou  i>   follow.-.l 

hv  lo.'al  (.■iiiioru.--  aii.l  coiij^.'stiou,  faiiitm's>,  p.^MMy  nausva,  (Iv.t, 
and  n-tl.•^^n.•<s.  I'sually,  all  -yinpt..iiis  liavr  di>app.afi-<l  afttr  t\v.^iity- 
foiir  lioiirs.  It  is  nromiiiciided  that  tlic  i>rori>durc  lie  r<|M'atf(l  iii  two 
weeks.  Followini,'  tlic  injection  tlieiv  i-  an  ineiva>e  in  the  baelerieidal 
pwerof  the  hlo.Hl,  and  aUo  a  very  marked  iii.reas«'  in  the  af:<:lutiiiating 
p)\ver,  whieh  may  per-ist  for  at  l.a-t  two  years,  as  in  eaM>  rein.rt.Kl  l.y 
Foulerton.      This   proet<lure   ha-  hoii   trie<l   on  a  larire   -eale   in   Iii<lia, 

and  also  in  the  S)iith    African  war.      Full   >tatistic>   fi i  South  Africa 

are  not  yet  avuilaMe,  i>ut  out  of  llK'i  per-on>  irio<'ulate<l  at  I,ady^mlth, 
only  2  per  <'eiit.  were  attacked;  wheiea-  of  10, .")!>!(  not  in.KMilate<l,  14 
per  cent,  were  attacked,  and  <if  iho-e  inoculated  the  mortality  wa-  0.46 
per  cent.  ;  of  those  not  inoculated  the  mortality  was  .">  per  cent.  Oil 
the  whole,  the  experience  ,-<)  far  is  stronirly  in  favor  of  iiKK'ulation. 
Such  a  method  is  naturally  mo>t  apj.licahlc  in  the  case  of  |)er-ons 
goini;  into  a  di-trict  where  the  (lipase  |irevail-.  or  in  the  case  of  armies 
or  other  lar^e  l.odie-  of  pcisons  likely  to  he  attackc-d  hy  an  enidemu!  of 
typhoiil  fuver. 


•i    ! 


ii  li 


\\t' 


I 


i  rM 


V.    TRI  A  rWHNT. 

OBSERVATIONS    ON    SPECIFIC    TREATMENT. 

A\  r.  iifi'  yi  t  I'll'  rcnii>\r(l  iVciii  ;i  -[n  .ilir  iniiiiin  iil  ni'  i\  |,||,,ji|  ti  \it,  /.  «■., 
:i  mnl,...!  cMii.ililr  of  (Ir-lr.iviii::  li-  lAriiin./  nni-r-,  tln'  i\  pli.  i.l -i.acilliis, 
ill  till'  liiiiiiiiij  ImmIv  ,mhI  |irr\ I'liiiiiir  i'-  'li--'  iiiiii:ii l^n,  i<v  m  I.  i-i  d'  ih  u- 

trali/iiiir   i>r   ;iiii  niiatiiiu-   llir   :irii\ii\'    i.i'  ii~    iM\iii~.   nlll jli  a  imihlur 

ot    nci  111  nli-trv  alii'ii-    -liiiniLilc   (.ii'in-l   iii\  (■~ii;.':ilii.ii    in    I  lii-  (lii'<(n' .n. 

Serum-lreatmcnt.  If  iIm-.>  ..t'  lo.-  .  \|.,  ri,  ihv  I.  Ii,\r.l  i|,mi  aTirr 
Hi'liriiiLr'.-  iiiL.'<iii'Mi»  ill  .'.A.-r-v  III'  ill. ■  arljcii  nl'  ||,,  ■iiphl  h,  i  la  -.  ri:in  ihc 
proillK'liuii  ami  llir  aiipliralion  ol  a  '-Iv  |i|iiii.i  Miain,  "  umilil  al-n  |ai.\r  i  nii- 
V»iiifiil  aii'i    iiiiX|i<-ii-iv>'.  lliiv   iia-ipiiil   uillmul   -ullii  iriil   I.  i;i,.!al  i..ii.      (  ..ii- 

olu-ii.ii-  l)_v  uii!ili',i:y  Mial  liii|i(>  liM-i  il  ii| till  In  an-  i  -|  .  riall\  lii  n  |  ii\r  in  the 

cliiiii"il  ami  l.acliTiiiJiiL'ir  lirM.  aial  ilu  .litiinilly  ami  llir  |:(  i  iiliai-iu  ol'llKcini- 
diliniis  alli-inllnir  ty|iliiiiilti\(  r  I  >|i(  I  iaiiy  luiM'  rivciilK  lnin  a;.'iiiii  (Itimiii- 
Mralcil  l,y  in\(T^li'_'aiiiiii>  inin  ihr  iiIhikiiiiiikhi  ,,f  aL!;j  li;l  ii.al  imi  aial  il>  n  la- 
linn.-  In  iiiiimiiiily.  \aiual.li-  |iri'liiMiiiar\  iii\  i  .-li_al  iiii;>  nii  llic  .-iilijcri  nl' 
SiTUiii-liaaliiiiiil  have  Ijrni  inaih  In  (  liaiiliiiu^M'  ami  W  iilal,  ami  i>]m  iailv 
liy  Si<Tii.  ami  iIum  ui|-r  riillnMil  l.\  1  laiiiim  r.-rlihiL'  aml\i.ii  .iak-rli.' « ilii 
iiivi-iiiiralinii^  iiili>  lln-  ili(i-a|ii  iilir  arii\ii\  i.iiIk  -iiiiiii  nf  I'diix  ah  m<-ii1s 
tVniii  ty|iliiiii|  t'cviT.  a^  "ill  a.-  l>\  llciinii  r  ami  l'ii|.i-.  I\  li  iii|  i  n  r  ami  i.ivv,' 
with  attfiii|ils  III  tnat  ly|ilioiil  il  \«r  ur.li  iiij(riiiiii>  nl'  ihc  urimi  of  iniiiiuii- 
izeii  aiiiiiials  i  .•aif"  or  iloi: '. 

Altiioi|i.'li  tiit'sc  oli.-crvalioii.s  l.avc  ili>riiiM'(|  a  liiniuil  inlluincc  of  ilie 
imiiuiiH"  scniin  ii|i(iii  cxiK'riniciilal  lv|.|ioi(l  inloxii-aiioii.  a  lli(ra|iculic  rcMilt 
Willi  n'fiTcncc  to  tyjilioiil  fiver  lia.-  not  as  yet  lici  n  inailc  out.  ami  tliis  coiilil 

scarrily  lie  fX|n'<'t(M|    lo  I iIutw  Im-.  in  view  ot'  tlif  iiilirf  (lill'tTciicc  ot'  the 

ex|ieriiiieiital  ty]ilioi(l  infcriion  from  typhoid  te\(r  in  hiiiiiaii  heiiiLTs.  llanllv 
more  than  the  iniKM  iioiism ->  of  .-mh  allciiipl.-  ha>  Im  n  <leiiioii,-iraleil.  The 
atteiii|its  ot'  Kiiiii|if'  tolnat  iy|ihoiil  fr\  er  with  dead  culliin.-  of  liacillus 
pyi«'yaiieiis,  haseii  ',i]iiiii  the  lhera|ieiitie  ex|icriiiieiits  of  K.  Fraiikel  with 
cultures  of  dead  ty]ihoiddia('illi.  have  received  little  imitation,  and  iheir 
results   have   not    vet    heen   continued." 

Even  at  an  early  jMrioil,  wlieii  only  iiideliiiite  conce|itioiis  existed 
as  to  tlic  nature  id'  the  Iy|)lioid  \irns,  certain  inelliod-  of  Ircatnieiit 
wore  em|doye(l  that  tnav  he  coti-idcrcil  anionir  the  s|iecilii'.  Anioiifr  llic-^o 
may  he    included    the   early  atteiii])ts   to  caiisp   an    iiicrcasi  d  iiiiiiiIkt  ot' 

'  .l»H    ■/'■  rhistitiit  I'.i'sfrur.   ls!rj. 

«  l)^„t..-l,    „,,;/    IC..,-/;..  IR'i-J;  :ir-l  /■:'  /   Ihy.  ii.  h,f,-kfhnshra»k..  \m\.  lid    x\i 

»  n.-i/s.-h    mr.l    ir...-/,..   ls!t:;,  •  I',,llak.   -/.rii.  f.  Ilfill;..  1807.  rcpriht. 

''  /.fit.    I.    /.':„.    M,'l  .    |S!i.-,.    lij.   xxviii.;  .■111,1    yrr/i,,,,,//.  ,!.   .XIII.    (■:,„,;.;■.    mn.    Me,i. 

'  Brrlin.  k/iH.   lf."7i  ,  Isii.",,  ■  J)r„fsr/,.  „,r,l.    Il'„,-/i.,   18',i3,  Nu.  41. 


;/..;/;       i(,i 


440 


TIU   I  IMI.S  r 


441 


Ht.HiU  Ipv   Miciiiis  lit'  i>iiri:ativ'-.  aii.i   iln;-   to  cllin   ,  limiii.iil.'ii    •.!'  iln' 

lyplinid   \il-U-   ll 1  ihr  iiil.Mili..       (i.,.l_\    ivlal..l  !■■  'Im-''  U'IV    .•.■n.iili 

innliM,!-  mI'  irv:iiiiHnt  lliiil.  --in-  m  -I.  |.  riinlni ,  u.Tf  .lire.  I.  ,|  |.,wanl 
tlriiir:.li/in._'al.n-iiuil  |.iilivl':i(!ivr  |,r.ict— .-  in  llic  ilitt-lim,  w  liidi  w.Tr 
,-.,n-iclc  Ti'l  :i-  iIh'  .--.iiii.il  f.Miiin.  'I'li.-r  i-c|iii>riitc.l  til.'  lir-t  allciniM.- 
ai  intestinal  antisepsis.  In  ilu-  cai.  _'miv  l,rl..n;^,  nn(loul.i.-.lK.  \\h- 
tnatnirnt  l.y  internal  administration  of  chlorin-water,  l-i- 
mcrlv    'nn.'h"    pra.ii-r.l,  il„'    1 1  :.n-lt..ry    .•n,|.|.._vni.nt    ol'  carboliC    acid 

aii.l   benzoates,    m.l    u..     iodin-potassiura-iodid    treatment, 

w.ii-nilv  iv.'.,imn.'n.I..|  l.v  -<an.r  ,in.l  Mair-ntN,  ami  Mill  .1.  rmcli'.l  in  tlio 
vrai-  i'm;i;  1>v   Will.lMiipl.'       W'liil'    li-  -    HH'tli'"!-  |>".--<-->   niily'lii-toia.- 

ii,t,.iv-i     al     iIh'    |.iv-,nl    .l,i>.    a    inrili...!    |..iilih'lly    alli.tl    t.)    lli.ni, 

nam.lv.  ili.'  inaiiiHiil  uilli  calomel,  -nil  lia-  ar.l.nl  a.lv..,'alr-  ani.mi; 
th..  niM-l  cil-lin-ni-li.'a  livin-  |.|iy-l.iaii-  (  1  .IrlH-rni.  i-lcr,  vmm  /icni-M'ii ). 

l,rs-cT.-  aipl  al'n  T  hiMi  ^.li. 111. ill,  ■I'l-aiilir.  ami  Winiclfrlirli.  iiinluulilcilly 
fsoiiL'liI  1.)  nliiaiii  Willi  llir  iTiiir.ly  lint  -iiii|il>  a  |uii-alivc  ftl'ifl.  liiit  alM)  a 
s|i.'.'illc.  Inrallv  ciii-aliNc,  |.o->ilil'v  ■.\\^<<  anliln\ic,  arii.m  a|«>n  tlic  inlcMinal 
imi.'oiH  iiHMiil.raiic.  Ii  wa-i  lirlirvi'd  iliat  lli.-r  cH'iiT-i  w.-n'  iiin.-t  nianil'i^l  at 
the  (•nmiuriHviiH  111  ..ri'i.'  .li-.'as:-.  an. I  u.-iv  .-ai.aMe  .if  iii.lmaii-  an  abortive 
liTininali'Hi.  ..r  at  l.-a-l  .niir-i.i.-ralili.  iniliirali.m  of  tlir  iiiti'iisily  nt'llii'  disyasf. 

Till'  mclliiMJ  .if  1  iii|)|..viin'nt  -till  rfv.iniiiii'iiilcil  liy  tlie  advocates  ..f 
till'  rninilv  iilacr^  ilir  lti'i.iIi'-'  iMi|Mirtaii.c  ii|m«ii  its  adiniiiistratinn  at  tlio 
oarlifst  [wis-ihlc  |iiri."l  nf  tlir  di-casc,  at  all  events  licfivrc  tlio  end  of 
the  iiiiitli  (lav.  (  )idv  a  snull  iiiiinhiT  nf  |)liysii'ians  lulicvc  'liat  the 
pciikhIv  lias  iinivid  ii~ifiil  al-o  alter  the  s<'eoiid  week  of  liie  disease. 
Doses  of  0.')  isr.uw  are  administered  at  intervals  of  i>ne  or  two  liotirs, 
^enerallv  three  or  I'our  in  llie  t  wiiitv-t'oiir  hours,  at  the  he^innilltr  of  tlie 
disease  (Liehermeister).  liieliernii'ister  iielieves  that  treatment  with  ealo- 
niel  indiiees  a  marked  miti._'^itioii  in  the  inleii-ity  of  tlie  disease,  while 
von  Ziem--eii,  ijoini;  somewhat  fiirlher,  attrihiites  to  the  reniofly  an 
infliienee  in  diinini-hin'_''  the  intensity  of  the  whole  infi^elioiis  condition, 
and  espeeiallv  of  ihc  local  intestinal  symiitoms.  In  view  of  the  experi- 
ence of  these  two  tni-tw.irthy  writers  1  am  iinwilliiiLr  to  advise  airamst 
the  emplovmeiit  of  the  method  in  siiiial)le  cases,  hut  would  emiihatically 
stiite,  with  Baiimler  and  Weil,  that  I  have  heen  niiahle  t..  convince 
myself  of  its  ahortive  and  ahhreviatinsr  ctl'eet.  What  I  have  ohserved 
was  an  incre;isc  in  the  nnmher  and  a  srreenish  di-coloration  of  the  st.Hils, 
oft"!!   with   tfaii~iloiy   depiex~ion   of  the  temperature,   which,  however, 

'  rin-//""-'.'  .tr.-A/v.   I'l.l.   \\\iii 

'  £)i>    EntzuihluH:!    iinil    {'.■•■.i.-hiniriin;!  ilrr   Schlnmhniit    :lrs    Diirmkathilr.i.    etc., 
Berlin,  1S30. 


;  I 


i     [ 


IIJ 


rrriinii'  1 1  \  1 1: 


■ 

|h 

|H 

$^n| 

'S 

1 

w 

i 


•iM 


HW 


I 


f'lilild  Ih-  citii-iili  Tfd  :i-  i,  n-ull  "I  iht-  cli;illli(:i  il-rlt".  Mini  li"!  a^  !l 
-[Miilir    ill'icl    i.|'   llic    illii.;. 

r  lliluulill  .il\  ,    In,      Hull     I  .ilir-hli  rilllnu    1|;|,-    hfl'll    ;.'IVfIL    to    I  lie    t'ilcl     lIlMl     tllO 

alMirlivi'  I'Mun-f  ■■!'  ca-i  >  •■{  |v|iIim|.|  Wwt  in  which  c'ahnml  lui.-'  hfiii  ailiuiii- 
ii^tcriMl  ill  the  iuiImI  imjhl  jii?-!  a>  wtll  he  ;illriliiili-cl  In  the  luiliirc  nf  I  lie  cmm' 
a.s  1(1  till'  in-aliii'iil  fiiii  l"\(>l.  '\'\\v  hir.'i-  mmiiiIu  r  dI'  caM*  of  lv|ihnii|  |'r\(  r 
pur-nil];,'  a  iiiihi  ami  Axml  >i>HT>i\  cmii  wIji'ii  ihf  (in.-ci  has  hccii  severe,  as 
Weil  as  liie  t'aet  ihal  liiis  iiuMiI.er  may  at  liiius  lie  ;.'realiv  iiiereaseil  withmit 
a|i|iareiil  cause.  .-Ihnijii  !'e  kept  in  miinl.  and  e.-|iecialiv  il  shniiiii  iim  he  t'ur- 
(.'Dlleii  thai  It  is  ini|M)Ssildc  in  ilie  lirsl  ila\>  nt'  the  ih:-ea.se  to  foresee  the 
eiiaracter  ot'  ils  siili>eiiu  nl  imioc.  iliat.  iiiiwe\cr.  tlii'  calnmei  treatment, 
evi'ii  it'  inclmieil  aim.n;.'  disint'eciMul  inclliiid-.  i>.  like  all  i.th'TS  of  its  chiss, 
without  sutlicient  ♦heoretic  t'oundal  inn,  will  shortiv  he  shown. 

'llie  earlier  eiideavnr^  in  tin  works  iit'  IJo^sliaeli  '  and  iJoiiciiard - 
with  rci.Mi(l  to  -\ -iiiiiatic  inle-iinal  anti~e|)-i-  have  lecciitlv  lieeii  taken 
up  uiiew  ill  accordance  wiiji  modern  view- and  iiicihods.  Thev  aim  at 
the  iiitrodiKtioii  into  the  iriic-iiiie  ot'  l)actericid:il  remedies  in  amount 
and  form  ca|)alile  ot'  di-iro\  intr  tiie  t\  piioid-liacilli  in  thi-  situation,  or 
at  least  ol"  inliiliitin^  iiicir  de\  eiopmeiit  and  di-semiiniion,  l^ossliacli 
teeoiiiineiided  tiir  tlii-  |)iirpose  especially  the  employment  of  liaplithaliti  ; 
while  Iloiicliard  emjiloycd  a  -cries  ol' remcdie-  >iicce--i\  il\- — in  addition 
to  naplithalin,  ^-najihtliol  and  ,y-naplithol,  iiKJot'orm,  -alol,  calomel,  and 
(dinliinatioiis  ot  -evt  ral  ol  the-c  leniedies  or  in  comliiiiation  with 
oilici-,  as,  for  instance,  iiaphiiio!  wiih  lii-iniitli  salicylate.  Tlie  iiietliods 
iiavi'  hitherto  recei\ed  little  imitation  in  ( iermanv,  while  Hoiicliai'd  in 
I" ranee  h,i-  inimcroii-.  in  jiarl  ciithii-iastic,  disciples.  I  have  persoiiallv 
made  hut  I'ev'  ol)>ervalioi|.  with  the  method  of  Kosshacli,  whicli  lias  a 
frail  t'oiitiilalion.  I  Iia\e  not  ventured  lo  follow  the  more  prcnise  direc- 
tions of  Iioiichard.  His  mithod  ii(|iiirt's  a.s  an  intioductorv  measure 
tiic  admini-tration  of  I  ."i  irrain-  oi"  inan'ne-ium  -iilpliate  evi'fv  third  dav, 
calomel  in  -mall  do-es  for  irt'ini'iil  aiiti-i  psis  for  foiir  d.iy^,  atid,  fiiiallv, 
daily  dose-  of    t  j.T.ims  of  naplithol  w\\\  '1  of  hi-mnth  salicvlate. 

It  would  take  us  too  tar  to  enter  fu  v  iiiio  the  scieiititlc  iis|  .cts  of  ttio 
method  of  trealmeiit  in  (|iiestion.  In  this  connection  I  would  refer  especially 
to  the  aclniiralile  investiLration  of  Stern,  which  le<l  experimeiitallv,  [irac- 
ticallv  and  theorelicallv,  to  iieL'ative  residls.  Al.so,  Furhrinirer,*  who  proj'erlv 
<'alls  attention  to  the  extraordinary  variations  in  the  luiinher  of  hacteria 
present  in  tlu'  -Innls  durini:  health,  was  iinahle  to  oonvince  himself  that  the 
introduction  of  antiseptic  -ul 'Stances'  into  th,'  intestine  was  eapalile  of  etl'ecting 
any  ditfereiice  L'reater  than  the  plivsiolo^ric  one.      An  especially  severe  blow, 

'   V.-rl,.,,i,ll.   ,/.    (•,.„.,.    I.    ,„,,     M,.l  .    1SS4 

'  /,/■--,  Ns-  ,«'/r  /'-•,■  n>itntfi'X!<'.  I'aris,  lss7;  anil  Thernpentiqur  r/r.s  malrniirn  infect. 
nuftsrp^i..'.   Pari-.   ISSM 

■*  Vul^^ninnn' <f  Snini>ihn'q  klin.  \\>rtr.if]r.  N.  F.  No.  IHS;  and  /'■//  f.  Ilvp.  u. 
Infr/iiium:':  .  l?'.-'d.  irl.  i:;.  '  JJru:~r-:.  rrr::.    ]',':rr:..  irS". 


Ti:yMMi:.\r 


4!.l 


finnllv    was  ii.flir't."!  iii«-ii   th.-  .luctri f  iiil.-tuK.I  n..li..<.i>M:'  l.v  llir  rr.-.tn 

nl.H.Tvatiniis  ..''   It.  Miillir.'  «Ih.  .|.-.n..MMr;il.-.l   .-uLrlu-ivrly  il,-   iini.riiiH.'ii 
l.il'ilv    II,    |„.i,lil,      mimI   .li>.:.,-.-.|    liunmn    liriiiL'-«   «illi    iM.'a.-urr^   .ivmiImLI.'   at 
pr.-.'nl       I'^'Mi  tlioUL'!.  il  u.rr  u.-mmiumI  llial  lli.r.-  .xi-lc  .1  a  i^m,  .-.luiv  rapa- 
1,1,.  uf  injuriti-  til.-   |.allio..'.in.-  iiii.T..-,.rL'ani-Mi.  m   -nal.r  .|.-ivr  aii.l  iu..r.- 
m.rfnai,..Mtlv  thai,   tlinr   l,.-i-.  n  ""uM   l.a\.'   Iilll..  valm^  u„   a,'-uu,  i  M   t hr 

r..lalioi,s  nftiM-  lv|.l,..i.l-l.acilli,>  t-  tlir  int. .  liiiv  an.l  il>  ' t.-nt...  piirlinilarlv 

in  .'ases  ,.nv|.l.ni,l  f..v.r.  li  i-  ki,..wi.  that  .vn,  at  a  .unr  «I»m,  th.-  a,^ea^J 
,|„esimt  uemTallv  .•oMU-  ui.I.t  „i,r.,Tvat.,...  for  ,naliM.-iM.  .•%.•„  uttri,  u  l,H. 
th.>  .•iini.iai.  lia-'  as  v.-t  i...  kimwlr,!-.'  ..f  ils  .m-i,.,,.-..,  .!„•  I,a,;,lli  have 
alroa.lv  |.a«s.Ml   fmm  lli.'   iiu.Min.s  int..  tlir   Inlli.lr:..  ih..  mlmmiIitk' L'laiMl-, 

ftu.l  nmr..  .ii-taiit  nr.'aiis,  .•,, ialiy  th.- .^pU-.-n,  ^^\n■u■.  naturally,  t hoy  an-  nu 

lonL'<T  ai'cessil)!.!  t"  antiw-ptic  rctntMlirst. 

It  is  llnr.-for.'  ju-tilialil-'  fnr  tiir  pr.M'iit  to  a>MirMr  a  .h.iii.ttiil 
attitiulr  t..waf.l  tlicantiMpii,'  iM.'tl.."!,  aiiM  .•vrn  i.nr  uf  -k.pti.i>ti.  will, 
r.v'aril  to  tlit>  li"!"'  tli:it  it  may  in  fuimv  pfovc  niurc  ^n(r.•^^t■ui. 

For  the  im'sriit,  anil  i.roi>al.ly  for  a  lon^;  tiinr,  thr  >u.c.»tiii  tr.'at- 
mont  of  tyi)li..i.l  fcvr  will  liav.  to  !>,■  pnr-n,.!  in  -ornr  otji.r  .iiivtioii. 
The  priiKMpal  fi<>t<,r-i  in  tr.atnn'iil  aiv,  tli.T.  ton' :  (  1  )  Tli.'  vtnTal 
appropriato  <"ir.'  an.l  reKmlatioi,  of  the  condition  of  th.'  paticiK,  (-|m- 
ciaily  in  a  diftclic  dirctiori  ;  I'J)  'i'lic  trratiiifiit  of  a  mimlu'r  of  ini- 
p.rtatit  manif.stations  aii.l  symptom-tcroups,  of  .•ompiicatioiis  aii<l  otlicr 
tlati!:.-roiis  accidents,  ami,  finally,  that  which  is  so  iniportatit,  oip.Tvi-i.in 
of  the  period  of  eonvalescein'e. 

NURSING  AND  DIET. 

Nursing. The  tvi)hoi<l   patient   should,  as  a  matter  of  nmrse,  ho 

keiit  in  hed  thronj;hoiit  the  entire  dnration  of  the  fehrile  state,  and 
bevond  this  into  the  period  .li' convalex-enee.  AlthoM<rh  now  and  ajrain 
anihiilatorv  cases  pursue  a  mild  eours(>,  others,  however,  are  attended 
with  such  profound  manifestation^  and  are  so  frequently  followe<l  l>y 
severe,  even  repeated,  relapses  and  unusually  protraetefl  ( ..nvaleseeii.e, 
that  one  cannot  oseaiM'  the  impression  of  the  hiirhly  injurious  inrtuenee 
of  an  amhulatir.y  course. 

Patients  wluw  circumstances  offi-r  no  assurance  of  aileqtiate  care  at 
home  should  promptly  he  sent  to  the  hospital.  The  management 
of  a  case  in  a  private  house  rerpiins  strict  rcLmlation  of  eNternal 
conditions.  Provision  for  the  utmost  physical  and  mental  reixise  on 
the  part  of  the  ]»atient,  and  onier  and  discipline  in  the  si<k-room.  arc 
nn.  onditional  reipiirements.  These  can  ^'cm  rally  he  attained  only 
throu^rji  well-tniitwl  ntirses.  M'l.en  the  care  of  the  patient  must  exoep- 
tionallv  he  placed  in  the  hands  of  the   imme<liate  relatives,  only  a  few 


'     I 


I 


444 


TYrii'ii/i  I  i:vi:n. 


^^t^ -r 


cf  tliisc  -liniild  III'  I'lilnisicd  wiili  tlu',-c  iliiiics.  ;in(!  tlitsc  shdiild,  tliirin" 
llir  |icrioil  dl'  llitir  ;icti\  it\  .  l)c  -i|i:ii-;il(il  I'nim  tlic  otlur  ii('cii]):mi<  of 
tin-  liiPiiM'  and  I'l-niii  tliii>f  ciiiiilnvi'd  ill  ihr  li<iuscliol(i,  ]iarticularlv  in 
till'   kinlirii. 

'I  lie-  -iik-ri«iiin  -Ih.uM  !«■  a-  lai-p'  a.~  |i«)>-il/l(',  -iMiatt'd  in  a  (|iiiot 
i|uarlti-,  and  la-ily  \  riuilatcd.  'I'lic  \tv-{  \\»<\\\  in  tnc  licu.-c  i.-  jii-t 
^■i"id  .■Miin^di.  'I'lir  ti'in|i(  ralurc  ot'  llic  niciu  .-lidiild  ix.t  he  alioxr  \-l° 
"I"  II  < '•  1  >nriiii;  I'avdiaMc  inrind-  nl'thc  year  tln'  windows  slimild  lie 
krjii  ..|itn  day  and  ninln.  and  cxm  in  winitr  a  tlidMUtrli  airing  slunild 
l)f  |ira(ti-cd  -cMTal  tinii>  ilaily.  In  li..-|iital  iiraclici',  and  w  licncvi  r 
|Mi~>ilil(  al-<i  in  ]Ti\',i.'  practice,  I  lia\c  the  patients  diirini:  tlu^  siiniiiier 
lie  tdV  liMnr-  in  tln'  njien  air,  witli  siiitalile  ]iiMte<-tidn  I'nun  siii!  and  rain. 
(ilariiiL!  liiiiii,  and  al-d  e>|ieei;.l  darl^enine-  dl'  tile  siek-roein,  arc  t(i  lie 
a\"id((l.  \  cry  iinii-nal  article^,  dicdralidns,  lljinie.-,  |iielMres.  and  tlie 
like,  aliniit  whicli  the  ]>llanta^ie-  and  the  dilirinin  df  the  |iatient  readilv 

ri'V(4\C,  .-ildidd  he  reinnved. 

The   sick-bed — makinL'  alldwance   .as   Car  as   pd—ihie   fdr  tlie    pre- 

\idn-.  haliil--  df  the   p.atieiit liMiild  in  any  event  iidt   lie  tdn  warm,  and 

shduld  lie  readily  ehaiiLred  .aiKl  reiideni!  clean.  'I'hdx'  severely  ill 
-lididd  lie  promptly  jilaced  npdii  a  uater-hed.  'I"he -heets.  whieli  slioiild 
lie  cliailLreil  \\liene\,T  -diled  ill  the  -lielite-l  deirree,  ~lidlild  Iliit  lie  tii" 
cdarse  ill  texture,  and  ne\er  wrinkled,  dii  .■lecdiint  df  the  danj:er  of  lied- 
siires.      Fdr    the    same    rea>dn    ininiediate   ennlact    nt'  waterprodf  sheets 

\\itl'  the  liddy  -hdiild    lie  a\di(|<'d.      While  at  iIk innieneeinent  <it'  the 

disease  ipiiet  r  •eiiinheney  in  the  ddi>;d  decnliitiis  is  the  niost  iialnral 
and  the  ind-t  advaiitatrcdiis,  at  the  lieiuhl  df  the  di~ease  and  toward  tlie 
•  ■nd  "(  (he  felirile  stiiL'c  chanLTf'  "f  ]>dstiire  >li(iiild  Ik  <'iieduraji('d,  and, 
especially  fdi-  tin  preventiini  df  |inliiidiiary  hyjidstasis,  fre(pient  alterna- 
tidii  df  the  ddr~al  with  tin  lateral  decnliitiis.  l-'vaeiiatinn  df  liie  Ixiwels 
and  the  lila<hier  shdiild  take  place  exclii.-ivily  in  ilie  reeiimi)ent  posture 
(non  iiil<i  liie  peiidil  i.f'  ediivalcscence.  Al>d,  when  the  lied  \-  cJianfriHl, 
till'  patient  sliduld  iidt  sit  iiji.  Init  always  remain  in  the  hdrizntitai 
posture — ])refera!ily  in  another  lied.  Many  a  ease  of  fiital  enliapse 
could   have   Iiei  n  avdidcd   liy  the  iihscrvaiK'c  of  these  ])rccantidns. 

That  in  in.iinlainiiiL'  -tri<t  cle.inlineSS  of  the  body  altetilidii  to 
tile  dorsal,  sacral,  ;ind  anal  rc^'iims  plavs  a  >peci;il  rnir  is  a  matter  df 
<'oiirsr.  Xcirleet  in  this  ri-peet.  in  conjiiiietidii  with  defective  cdiidi- 
tidiis  (if  the  hed,  le.ad-  Id  the  de\(ldpnient  df  hed  -ores,  whicli  are  but 
rarely  depenilent  upon  t'-e  nature  of  the  disease.  Imi  almost  always  njvtn 
<lcricieiieies  in  niir>in<r.  K-peeia!  consideration  should  lie  jriveii  to  the 
mouth,  the   lips,  and    the  teeth   of  the   patient.      Frccjiient,    thorough 


Trj:ATMi:sT. 


115 


.•IcMii-in-.  .'-lM'<i;illy  alur  tli,'  in-.'.-timi  of  In,.,!.  tVc.|.i.i.t  n.oi.i.nin^'  <>{ 
,|„.  li|,-,  :m.l  ihr  liv.|iiriil  iirollcriiiL'  of  Miiall  (|iiariiilU'.-  of  lluid,  arc 
ii!,li-pciisal.lr.  A  \v.H-iiurM<l  |.ati.nl  may  only  t.Tiiporarily  oxliii.it 
,lrv  tonjruc  an.l  lil'-.  and  iirv.r  a  fuli-ino,,-  ,l,.,..,Mt.  In  wonu^.i  -mit 
care  .-iioiiM  from  tlu-  "iiiM't  lie  irivm  to  iIk^  iiair.  whi.'h  -ImiiM  l.c 
,.o„,l„..l,   un.l.T   ^oMH    rinuii.-ian.vs  <-ut   -lioit.   or   i.nlVnil.ly    l.o   worn 

in  a   iirf. 

Diet.— With  n-anl  to  fow  points  in  connection  with  ty- 

nhoid  fever  i^  tlurc  at  tli.'  im-nu  day  siicli  .-atisfactory  a>:nrmeiit  a;^ 
with  n-:u-.l  to  thr  <hct.tir  iiiaiiauvmrnt,  of  wiiidi  the  iiriiiciplcs  cau  he 
,.on-i.lrn.l  a^  fully  ■■Mal.lislu.l.  Thr  |u-oMrm  ihvm.i.H.I  t..  tho  phy.-i- 
..jan  an.l  dcman.hn-  tan  an.l  .li-.  iin.inali..n  .•..n-i^ts  in  a.laptiiig  these 
piincipU-  to  the  n.M'.l-  ..f  tla>  in.livi.lual  ca..'.  In  ^r,,,„.ral.  the  .Hfli- 
eiiitiesan.i  jHriiliarities  in  the  n..nri~hin,iit  ol'  tyi.h..i.l  j.atlents  are  t..  he 
'....,k<Ml  f..r  in  t\vo.iire<ti..n^:  in  tiie  .•.,ii(liti..n>  atteiuhn^' 'he  infeetive 
or  the  fehrih'  Male,  an.l  in  th.ise  a-.-.ieiate.l  with  the  local  .•haiiges 
in.htce.1   hy   the  typlM.i.l   i)r..ees-    parti.ularly    in   the   inte^line. 

The  maiiif.stations.if  the  t.>xi.'  aeti.>n,  parti. 'ularly  the  f.'hrile  e..n<li- 

ti..n,  are  attended  with    iir..toniid    metal...li.'  di^nrhaiiees,  a nj;  whieh 

the  active  .l.>tru<'ii.>n  ..f  the  h.Mly-pr.itei.i  ].lay>  an  important  /.'./,•. 
It  is  the  m.>st  imp..rtant  pr.ihlem  in  tlieteti.'  tr.alment  t..  sliiel.l  the 
j>  '..ids  from  this  .lestrnctive  j.to.rss  as  far  ;.  nos.-ihU.  l.y  th.'  a.lmin- 
i,«,  ,ion  ..f  .•arh..hy.lrates  an.l  eneriry-.-n>tai!H,,jr  t'.«'d.  it  miiM,  fur- 
th..rni..re,  he  t:'  n  into  ciisideriti  .1.  that  direct  replacement  ..f  the 
di^inteJrratin;:  |.:.,t..i.ls  thr.mgh  the  f....d  is  p.,s-ihle  oidy  in  a  wholly 
ina.le<piate  niann.r,  .ui  account  of  the  f^.hrile  deranjrement  in  dijres. 
live  aitivity. 

Naturaliv.  the  l).>.ly  nutriti.m  is  jrreatly  di>tnrl>tHl  in  many  other 
din'cti.ms  al-.),  esjH'..ially  with  repir.l  to  carhohy.lrates  an.l  fats.  It 
shonl.l  he  borne  in  min.l  that,  in  a.l.liti.m  t..  the  ])r.idiieti.>n  ..f  hydro- 
ehl.vric  aci.l  in  the  -t.ima.h,  tlw  fnnetions  of  the  sdivary  glan.ls,  and 
pr.iiiahlv  th.iM.  ..f  the  ]>an..r..as,  are  seriously  itTipaired,  an.l  also  the 
se..retion  a.  .1  th..  con-lituli.in  .>f  th.'  hile  are  altere<l.  c.)nditi.>ns  that 
dcman.l  ..an.f.il  s(.li...tion  an.l  |)n.parati.in  .'f  the  f.iod,  all  the  more  sine., 
peristalsis  an.l  absorption  appear  t.i  he  al-o  invariably  impaire<l. 

A  further  ..^pei'lally  imjy)rtant  ))eenli;irit"  'if  tyjihoid  fever  with 
refjard  to  the  di..t<.ti..  manasremeni  is  it-  I  .'  dnration  as  compared 
with  other  intcctLms  diseases.  Th.'  nnt.'ii.M'  .li-tiirban.'es  resiiltin<r 
fn.in  the  m.irbi.l  pr.M>ess  as  a  re-\ilt  attain  an  e-^iMH-ially  hiirh  trnide. 
Th(.ir  anjrm.  i\tation  i-  piv.jjressiv..  with  the  continnance  of  the  .hsease  ; 
and  thi^  naturally  increases  materially  the  difiicnlties  .)f  ireatment.  an.l 


:   y 


44(i 


rvi'iiiiiii  I i:vi:i: 


I 


^p-^T-  ■ 


1> 


!  M 


"iiii 


>liMiil(|  I,  ail  ihc    |)liy,<iciaii  to  a.ljust    liis  tin  r:i|)cut 


ic  incatiuri's  .-v.-tiiuati- 


calK    iViiin    llic    liciri 


A 


iriiiiinii:. 
Mi'Mii:   till    ( -idi  rati. Ill-   ari-iii''  inil 


III    ihf  Ideal   altiratiipii,- 


(li  |"nilcrit  ii|>iiii  ilic  -|pi(itic  iiiic-tii 


'rill 


lal  lr-iiiii>  |ii(|i(iii(l(rat 


!■  iivcr  all  ullici>. 


|iliy-i(iaii  caiiiiiii    inaki'   it    Millicinitlv  rlcar  l^r  liini-cir  in  tl 


ifctiiiii  that   till'  iiit 


-tiiiai 


i|ilii|ii-    cliiiicallv  stand 


in   III!  ijirci 


lis    Cllll- 

■t   rcla- 


i.-o 
ic 


li'iii  to  till'  (li-triliiitii.ii  and  the  -cwritv  of  tiic  aiiati.niic  li-inn.-,  an<l 
lliai  cvcfv  >a-.'.  iwn  a|i|.aiviitl_v  tli,.  niildot,  may  l.c  altcn.lul  with 
cMrii-ivi-   and    |iriil'iiiind    inii-iinal    iilnratinii. 

KiiiMiinatrly.  It  i-  i  iiliivly  |.,i--il,l,^  at  the  pfonit  day  to  make  ].orrwt 
all"uaii(v  lor  tiic  jinal  ci iiidili. m-  wltlmiit  ivliii-ninu-  tu  tl-  |Mi.-iti(in. 
ii'iii:    aliand.iiiiil.    .if    a     \\at.r-.ii;|,    aii.j     iiiiiitriT-diiit.      <  )\vini;    to    tlie 

iMH-lit  of   Miiudi-li   iihy-i.iaii-.  mid.  r  ilic  oiii<la f  Crave.-,'  to  wlio.se 

.-ll|i|H.|-t  e-i.e,ially  M  iirehi-.  m  -  .lief-eli.-aHy  devoted  liiin-elf,  tlu  i'olloW- 
iiii:    pi-in.i|,|e    i-    rer,iu-ni/,.,|    at    III,,    piv-ent    day  :     \\e    eaii    and    inn-t 

''""r  iH-li  iiiir  iy|,iii,id    patient-    frmn  ilie  .,iit>et  ;    ue   -lioiiM    tlierehy 

'•'"''•'^"''  '"  njilai-.  llie  <li-inl(-raliiiL^  |>i  .teid-,  or  alletiiiit  at  lea-t  to 
limit    till'  de-triieii, 111.  I,y  mean-   of  ,.|i,  r-y-prodneiiiir  Mih-Ianees,  earlio- 

liydrate-,  lilt-,  -eiaii i-  -iil,-tanee-.  and,  linally,  aJM.  aieoliol. 

Ill  aee.irilaiiee  uiih  tlie  i;.  ii.Tal  and  Ineal  jieeidiarilie-  of  the  di.-e: 
already  mentioned,  however,  iliroii-liom  tiie  entire  duration  of  i| 
telinie  -late,  and  f.ir  a  eertain  jieriod  |„.yond  this  time,  all  .-irtieles  of 
food  -lioiiKI  he  jriveii  .iiily  in  a  llnid,  readily  dijjestihle,  ami  casilv 
ahMirl.ahle   form.       I'"rom  t!ie  -ame  |M,int  of  view,  eare  -hoiild    he  taken 

'liii'    ' ■i-hmeiit    i-   uiveii    fn  i|iiently.    in    severe  ea-es    hv   d.-iv    ami    hv 

iiiirht.  alway-  in  -mall  animint-.  at  interval-  of  two  or  three  honrs, 
ami  that  al-o  -omiioien;  |i.alient-  -lionld  he  imhieed  hy  the  attendants 
t.i  take  food  leLM daily.  <  >ii  the  oilier  hand.  e-|ieeiallv  in  private  piae- 
li.'e,    overieeiliiiL'   of    the   patient     -hoiild    he  eaiitioned    aj^aiiist,  and    it 

-lioiild  1)(>  made  ele.ir  from  tin tset  t..  the  o\  (.r/ealoii-  friends  that  the 

l>hysieian  eaniioi  hope  diirinL'  the  fehrili  stajre  to  make  j^oikI  t'litireiv 
tlie  loss,  hut  tliat.  hy  na-oti  of  the  re-t  of  the  patient  in  li(.<l  and  the 
ollierwi-e  dimini-hed  phy-ieal  ami  |)-veliie  expenditure  of  enerirv,  this 
i-  of  little  -i._'niiieailee.  and  lliat  the  lo—  eali  snl)-ei|Uentlv  he  readilv 
retrained. 

In     -ome    p.atieni-    anorexia,    even    aetiial     repiiiruaiiee    for    the    food 
hitherto  admini-lered.  m.iki-  it-  a|)peanm<'e  at  the  luiLdit  .if  the  I'ehrile 


'   Cliiiirnl     l.i;-ti,r.-s    ..}!    tl.r    I'r.i.-t'fr    ,.f     M,;l,.-n,r,    sp.'niul    i.ilti.>n.     DuMitl.  18-18. 

Tlii-  \v..r!,  .  ■lit. lit,-  th.'  f.Un.Mi-  M.il.-hi.-i.I  .fi.'ii  .|u.i|.-.l  ■  ■■  If  y..ii  sh.uil.i  Lp  in  iK.iil.t 
U'  I'.  Mil  ci.ihiiih  t.i  li.'  |i|;i.'...|  ii|i.iti   iiiv  L.'rn.'.  i.'il<.-  ilii-      •  H.'  f.'ii  tVvi'rs  '  " 

•   Thr  1\n,l,^.,.l  /»,.«■. M,».  (;,Tni!iii  tnin-lnti.in  by  v.ui  /iiizpr.   Horliii,   18r,7,  p  -^M, 


Ti:i:ArMi:sT. 


Ul 


state,  ill  a  lar;zt'r  iuiiiiIht  diirinj:  tlic  .-(((iiiil  |>crii«l  of  tlic  disease.  'I  lie 
cxixTiciictKl  ]iliv.-ici:iii  will  (•.niiitciiicl  lliof  iii(iil)itl  iiiaiiit'otatiuii-  nut 
!)v  uniiccfssarv  >trittin>>,  hut  \>y  appropriatt'  individiiul  selection  ami 
variation.  A  tVhrtle  Ivplioid  patient  is  not  a  .-nlijcet  (or  |>e<lantic 
trainiiH'.  Under  siicli  <'ireninstanee>  the  widest  will  vield,  and  this 
the   pinsieian    ~hoiild   l)e. 

Drinks. — Kven  more  tVeciiiently  than  deran^^eiufiit  of  appetite, 
coinplaint  is  made  dnrini,'  the  I'ehrile  period  of  thirst,  and  in  somno- 
lent patients  an  elforl  will  he  made  on  the  part  of  the  I'riends  to  (pieneh 
the  i)arehed  eondiiion  hy  a<hniiii>tration  of  fluids.  In  contr.ist  to  |)re- 
vious  views,  the:-e  desires    may  lie  nnconiiiti<inally  ae<ede<l  to,  naturally 

with  a  consideration  of  iiidividu;d  | uliaritie-.      E-peciaily  cold  Ik'Vhi-- 

aj;es,  pro\  ided  thev  were  well  hnrne  durinir  health,  and  even  the  addi- 
tion to  them  of  ice,  need  not  he  rc~trieted.  The  liest  drink  tiir  typhoid 
patients  is  ordinary,  ^'ood,  clear  water.  Al-o  <ertain  natural  mini  ral 
waters,  as  those  of  Setters,  ( lie^liiihel,  Uilin.  ami  others,  may  he  per- 
mitted ;  whih'  artificial  waters  should  he  forhiddeii,  on  account  of  the 
e.xcessive  amount  of  t'arhoii   dioxid   they   contain. 

Wiien  the  patieiit.s  exjiress  an  especial  desire  for,  and  the  intestinal 
eymptimm  do  not  contra-iiidicate  their  use,  fruitjui-'es.  such  as  syrup  of  ras-p- 
herrv,  leinoM-jiiice,  ami  oranjie-juice,  may  also  he  added  to  the  water.  Some 
phvsicians  prescrihe  ahiioml-milk,  wlii<'li.  however,  is  tolerated  hy  only  a 
few  patients  for  any  leni,'th  of  time.  Still  hetter  home  than  thest;  things  is 
addition  to  water  of  red  or  white  wine,  and  also  eoirnac  or  sherry.  For 
individuals  with  an  irritalile  intestinal  canal,  weak  cold  tea  has  invariahly 
answered  adinirahly  in  my  hands.  I  am  not  fond  of  i)re.-!eril)inf;  alhumin- 
water  or  irum-water,  or  of  liread-infnsion  or  mucila;^iiious  drinks.  By 
means  of  these  the  appetite  of  the  patient  is  spoilecl  for  actual  nourishment, 
and  ill  addition  the  keepinj;  of  the  mouth  clean  is  therehy  rendered  uuneees- 
Barily  diHieult. 

Amoiifj  actr.:il  articles  of  tood,  tlie  first  jilace  should  he  ^iveti  to 
milk.  Tiieoretieallv,  this  ajipcars  iindouhtiHlly  to  he  the  most  nitional 
form  of  iioiirishnnMit  for  fehrite  ])atients,  iiiasmtich  as  it  represents  the 
ideal  coiubination  of  jiroteid,  fats,  carbohydrates,  and  salts  in  a  li((iiid 
form.  Espwiallv  the  fats,  which  are  so  important  for  fohrile  patients, 
and  utilized  with  so  inuch  difficulty,  are  most  finely  divided  in  milk, 
and  are  in  the  form  of  an  extremely  permanent  emiibiiin,  and  are 
therehv  rcnderwl  as  easily  assimilahle  as  pos-ihle.  .Mthoiiirh  some 
jihysicians,  aecordinirly,  .-idvocate  an  almost  exclusively  i.iilk-diet  in 
cases  of  tvjihoid  fever,  it  may  he  ol))eete<l  that  not  many  patients  rare 
for  it  for  any  leiifrth  of  time,  and  a  still  larpT  numhcr  do  not  hear  it. 

The  ))atieiit8  then  eoini>lain  of  pros.«iire  in  llie  epitrastriuni.  a  sense  of 
fulness  or  of  ahdominal  tension,  and  of  pyro;  is  .-ind  eructation,  tmd  the  stools 


';    '! 


5 


'ii: 


w 


v-^. 


tf  m 


7%^- 


m 


li. 


448 


TV  rill  nil  I  i.vr.n. 


ciin;:iiii  >liL'lil!v  altimi.  cdiirM'  rn:iL'ul:i  nl'  milk  in  uiiiloirMlilc  Miiiomit. 
Mu.-i  t'lr.jiiiiiilv  ilif  Milininitiinilioii  ul'  milk  i.-  ih-cvi'IiUmI  Ip\  iIu'  liu'l  ileal  it 
j.'ivi'.~  riM-  In  llif  I'nrriialion  in  tlii'  >t(im!icli  ot'  t'clirilc  ]iatiiiil>  cit'  lirm.  Iiiiiipv 
coaL'iila.  uliich  an-  willi  ililiiniliv  ilip'>l<il  Ky  rraMHi  oi'  llic  ilimiiiulioii  in 
hyilrocliinrii'  aciil  |in'M-iil.  Tin.-  ran  at  time?  lie  avuidi'il  liv  ailmini>lcrini.' 
only  l)()ili'(l  milk,  lliu  cnaLMila  d'  vnIiIcIi  ai-c  miI'ht  and  >n!all(r.  Piluiion 
with  ordinary  walcr,  mineral  \\attr.  or  linii-watiT.  also,  mav  In-  u\  .-crs  it'r 
in  lliis  rdnni'diciii.  It  i.-  |'anii'ulai'l\  ad\  antaL'ci'n>  nlicn  tci  add  iiiiicilairi- 
iKiu-^  ^llilStanl•(■^  ti'  till'  iiiilL,  .-ui'li  a>  nalmcal.  la|>in(a.  arrnw-rniii.  and  .-indlar 
arti'-lfs,  Sniiic  |iancnt.>  tidcralc  tin-  addilinn  niVail  nr  cnMiiac  !•■  the  milk  to 
iMiproVf  the  ta.-ii'.  (lth^■r^  arc  ^rratctul  I'or  |  t-i  ini.-^inn  to  lake  tlic  milk  in 
the  tdrm  nt'  kiplixr.  I  nder  >w\\  ^irl•nm^tall(■^■^.  it  i.-  lru<-.  iKf  i'i>n>idrralde 
amonnt  lit'  carliiin  liiiixid  j.rr-.  nl  ^ll■'^ld  \<r  hnnu-  in  mil 'I.  At  linasthe 
ailminislraiinn  i<\'  luittcrinilk  ,-i  :\  i  >  a  nx  lid  )iiir|i(i.-i'.  A  IiIiimi::Ii  il  mu^t  lie 
con.-idcml  as  |. -s  \alu:''  If  en  aci'i.unt  nf  llir  alisi  i  re  ol'  )'al,  il  is  casilv 
ili'ji-iililf  ti'r  till'  n  asnii  limi  in  (■iii!>(i|iicii(i-  nl'  ilir  nurhanicid  intliicni-cs  to 
uliirii  il  is  suiijnU'd  i:i  tlit-  makiiiir  nl  l.iiiti  r.  the  lasi  in  it  c-nnlains  is  in  an 
fs|ii'iaally  linr  stair  nl'  .livisinn.  I'nr  ]ialiriits  wlm  I. car  milk  very  well,  tlio 
adilition  of  ircani  mav  l.c  I'crmiticd.  'I'n  >..mr  laiifnls  tlm  admiidstratioii 
ot"  milk  in  a  trn/cn  slate  is  n.nsl  aijrctal'li  .  Snili  i.t-crcam  is  iircnarcd  liy 
I'ri'f/.iiiLr,  in  a  sliallnw  \i-scl  nr  liv  nuans  ni'  a  mld-mixlnrc.  milk  wliii'h  luis 
lifcn  nondcnscd  in  a  vaciinm.  and  In  wliiili  lias  Lien  addi-i!  a  small  anmiint 
of  siiLrar,  and  for  tliosc  wlio  {'arc  t'nr  it.  ciniiamon.  vanilla,  or  ihf  liko. 

A  lint  Ic.-s  iinjinrtaiit  /oA  ;>  |ilayi(l  li_\  tlic  adniiiii~tralinii  nf  carbo- 
hydrates in  till'  ('•iriu  nl'  iiiiicilMoiiKJii-  miii]>,  wldcli  may  he  n-jven 
alniio  nr  tnixctiicr  w  iiii  nilicr  iiutiiciit  or  stiiiuilatiiiL:  articlis,  csiR'cially 
wiili   hciiiiljnn   nr  jiriilrid-. 

In  nrilcr  in  nndi-r  n  '  ral.li'  I'nr  snmc  tiii'c  llip  mucila$r|nouS  Soups 
wliii'li  am  sn  luM't'ssarv.  ii,.-  |i|ivsii'ian  must  have  a  wiile  rani:c  of  fnrninlse. 
AmniiLT  ail  till'  suUslaiicfS  to  lie  taken  inln  cniisiiliralion  in  tliis  ■  rnnectioii, 
oaliiu-al  has  tlie  ;rrfaU'sl  nnirilivc  valni',  nn  ancnunt  of  the  ndaiivcly  larire 
ainniiiit  of  fat  and  prott-id  il  I'ontains.  I  nfortniiatclx .  it  often  earlv  exeiles 
th'- distaste  of  (liP  |iaiienl.  I'laler  sneli  circuinstaiu'es  it  should  lie  allprnated 
with  rice,  ulicat.  irreen  corn,  inai/.i'.  ta|iioca.  |ialni  sai:o.  and  the  like.  I 
Would  further  rccominend  es]iecialh  the  addition  to  sniips  >A'  alenronat  flour, 
which,  as  is  well  known,  contains  •'^d  per  cent,  of  proteids.  is  solulile'in  water 
and  is  not  coai.'nlateil  liv  heatiiiL^.  and  >\liich  is  admiraldy  home  hy  almost 
all  patients.  In  the  I'a?  ■  ot'  children  anil  ynuiiL'  adults,  success  is  often  had 
with  artificial  I'ood  .  Nesilc"s.  Kiifecke's.  and  others  .  Snme  patients  like 
the  adilition  of  white  or  red  wine,  iiisicad  of  houillon.  to  the  hrolh.  In  the 
l.-iler  siaires  of  the  diseaM'  — as  ih.  stajc  ot'  sleep  ciirves  and  that  of  dei'er- 
Vescenc( — certain  other  addilinns  mav  !),■  made  si:cli  as  h  L'ninins  or  Harteii- 
stein"s  leLrnminose. 

.\iiniiii;  the   niilriciit    •■ind    stimulant   .•iitiilcs,  meat-broth  jirepared 

.at  home   is  hv  tiir  the    mn-t    in   he    recnninieiidcil,  and  in  prepariiifi  this 

it    shiiiili!  he  noted    that   the  meat    nt'  fnll-;rni\vn   animals  (cnw  and    nx") 

enntaiiis   a    lar^'^er  aninuiil    of  extractives,  and    that    nf  veal   and  yuiiiifr 

fowl   a    smaller  aniniint. 

In  the  care  of  sensitive  patients  the  presence  of  fat  in  houillon  should  he 


Ti!i:.\rMi:\r 


-J4!> 


avoiiii'ii  :is  I'liliv  :is  |mismIi1c,  aii'l  I'li^  ih:i\  Kt-  >iitfii'iiiiily  illi*rtf'l  nV  jn-rmit- 
titiL'  il  I"  >•'>'■{.  ;uiil.  lifliiri'  licaliiiL'  it  iiiriiin.  .-kiiiiiiiiiiL'  "li'  lln  i"'':!!'!!!:!!!'!! 
laviT  lit'  tat  uii  the  -iirt'icf.  h  i<  still  nmrc  iiilvi;'aM>'  in  >iii-li  imm'.-  to  [ire- 
iiaro  till'  iiii-at-!iniili  li\  aiMiiij-  Imt  \\;itir  ipr  nuicila-.'e  Id  n  ilcliriilc  aiiiuiiiil  nf 
•■  liotilo  l)(Miill(iii.  "      'I'lii'  li(-l  iiiinlr  (it'  |irc|)aratioii.  isprcially  it'  tlic  itirsciice 

uf  ijflatiii   also   be   desired   at    tin-   sa tirm,    ecinsl>t.'   in     Iniiliii;.'   iiver   tlie 

water-liatli.  tiir  t'r.)iii  Uvu  to  t'oiir  lioiir>.  e(|ual  parts  ot'  veal  or  lieet'.  willioiil 
the  addition  ofuater.  'I'lie  jniee.  e\|ire>.-e.|  ilirouidi  a  el.nii.  wliieii  at  times 
is  ([uite  clear,  niav  lie  u>.'d  in  tlie  manner  de.-erilied,  as  an  addition  to  nnik 
or  laUeii  rold   in  llie  I'lrin  o|'  i'll_\  . 

A  larire  ninuiier  ot'  arlilieiai   |iro.hi(i~  have  lieen  |ilared  u| tlie  market 

for  tlir  |ire|iaialioii  and  t'o|-  ineiea.--;n'j-  llu-  r I'ntration  .>t'  lionillon.    A  niitnlier 

ot'  these  are  I'ree  t'r'ini  olijeeiiou:  lioue\er.  some  are  iiuile  eX|ien>i\  e,  and 
at  anv  rate  tlii-\-  oil'er  no  alvantaL'e  over  the  lionillon  |ire|iared  at  home. 
Ot'  the  nio,-i  a|i|iroved  ot'  tiie-e  there  mav  lie  mentioned  l.iehiL''.^  eM  laet  ot' 
tieei',  l!r:ind'>  .— ■  lee  ot"  lui't'.  and  \'!dentine'>  mealjuiee.  ('lo?e!_\  related 
t,,  ihein  are  'lie  so-called  meat  I ie| itone-.  which  acimilly  ]i,.-e.s,-  hut  little 
nutritive  value  and  onl\  i  he  inllueiici'  ot'  the  e-vtracti\  e.--  and  the  salt.s 
contained   are   to   he   taken    nilo  consideration. 

Ill  additi-iii  In  carli.ilivdfate-,  the  gelatinous  substances,  uhidl 

in  (lerniaiiv  lia\e  Im'Ii  atraiii  re-toi-i  d  tn  t'a\iir  liy  Seiiatnr.  may  he 
liieiitiiiiied    a>   an    adiiiiralile    means   ".    -liiehliii<j:   the   lHMly-|)fiiieids. 

The  jeliv  is  hest  prejiareil  t'rom  calves'  feet  :  hut  under  sonic  circum- 
stances it  mav  also  he  made  t'roui  l'ooiI  varieties  of  commercial  Litlaliu.  It 
mav  he  administered  m  the  t'orin  of  lui  addition  to  soup,  in  the  firm  of  the 
"hottle  houillon  "  aliead\  mentioned,  or.  \i  hat  i-  es|ieeially  retVeshimr  to 
inaiiv  patients,  in  the  form  of  uine-jelly  or  fr!iii-i<lly.  I-"aslidious  patients 
will  he  L'ralefiil  if  the  irclatinous  adililioii  to  >oup  he  made  in  the  firm  of 
crali-jelly  or  oyster-jelly. 

Smie  ri'-ivvr  ^iimiid  he  e^ceised  in  tlie  adiiiitiistnilinn  uf  actual 
proteid  nourishment  in  ca>e-  nf  typiiiii<l  t'evcr  diifinir  the  r<lirile 
.statre.  Solid  inc.it-f'Mid  nf  any  kind  slinnld  he  -trictly  t'orliidtlen.  .\i^n, 
eggs  should  lie  oivcii  onlv  with  cantinti,  in  espec  ial  f'nrin,  and  shnuld 
never  lie  nrire<l  njiiin  the  patient.  They  are  irrncrally  ]ierniitt<'il  to  lie 
taken  fa.v.  and  iinlv  the  volk  ~tiffed  in  -nil].-.  In  additinii.  the  yolk 
nuiv  lie  ixiveii  lieatcii  up  with  liniiiUnn  or  wine,  p.articiilafly  port 
or    ,-lierrv.      i'liri^-    adini\cd     with     tnilk    are    inticli     more    lUtlienlt    nf 

(liec-tinll. 

In  (  >-ler"-  clinii'  at  the  .Inhns  llnpkin-  Iln-pital.  co'Ll-alliiiinin  is 
verv  I'reeK  iriven  tn  typhoid  jiatient-.  ii-nally  in  tlie  tiirin  ni'  allmniin- 
water.  In  preparinir  this  the  allinrnin  i-  tlinrni|o-|ily  -liaken  with  Ico 
and  a  small  ainntnit  nf  water,  tiliii  is  then  >ti'ain(Hl,  and  (lavnred  with 
leiniin,  -lieriy,  nr  lir:ii;dy. 

\'on    Zienissen    espeeiallv    reenniniends    meat-alhnmin    in    the    form    of 
recenllv  exjiressed  beef-juice,  which  has  lieen  incorpnraled  into  the  German 
Pharmacopeia.      This  contains  tJ  [xt  cent,  of  dry  proteid  (  Voit  and   Bauer), 
Z'J 


1 

1 

i 

Wl' 


li:l 


s 


450 


TYViioih  I  i.vr.i:. 


and  niiyiariiitlv  is  Muilc  cii-ily  ili^'i-.-iiMf.  Il  i-  "til  l«iriH-  liy  niiiny  patifiifs 
as  ;iii  ailililii'ii  in  -uii|i.  iiinl  \<\  i.ilici>  uliiiic  in  a  lii|iiiil  <ir  iVn/.fn  slali'. 
I'(ir  -iii:-iiiv.-  I'liliciil^-  llii-  ailiiiliiiii  III'  |i<].|icriMiiit  i-  a  l''"..!  cnrri-ctivf. 
Wiuii  !!]<■  I'atiiiil^  ..Ljicl  In  ilii'  tiirliiii,  lilnniiy  a|'|'iar:ii:cf.  liu-  lluiil  iiiav  he 
ailiiiiiii.-lci-i(l  ill  a  LTitn  L'la.-.-. 

(  It' artificial  proteid  foods,  a  clear,  llii.k  jiiicM,  madi-  inliiisily  red  li_\ 
aciiiiiMurf  willi  licinnL'iiihiii.  ami  .loi.'tKiUii  |iuin.  |,iir  rrnnlly  l.i-cii  recoiii- 
niciiiicil,  uliirli.  aiciiriliiiL'  in  liu  -imIcmu-mi  nl  ilic  iiiaiiutiicuircr.  cnnlains  '_'(» 
|nr  r.iii.  nj' |,rnu  ill.  liul  llii'  \ali;.  nf  \\\,\i\\  ^iiil  rc.|nir«.-  liiiiii'il  iii\<-liL'a- 
lioii.  (  li'i-a.-iniiallv.  llic  inc  at-i'i-c  |iaialinii  nl  1  .i'ul'< -|;..m  idlial  inay  lie  valii- 
alilf.  (If  llif  iiKal-]ii|iiniii -.  nl'  uliiih  K(iiiiiuTi''li's  and  I  Kiiaycr's  may  lio 
nii'iuidned.  I  ranly  iimkr  iim  .  Ilir  |i|i_\>ician  i-.  nf  late.  iVciniciil  ly  iin|.nr- 
tuni'd  liv  tlic  I'ricihl.- nl'  tlic  |.aliinl.  wlm  nllcn  lia\c  l.ii'nnic  t'analio  nii  llif 
i)iif.-li(m"nt'  iiipurisliiiirin.  to  iiM'  -lill  nilicr  nf  tlir  inndfrii  priilcid  prcpara- 
tion^.  NiilriiM'.  ^nnlaln^^  .  aiid  I'lua.-ln  arr  ilmsc  nin>i  cnniinnnly  nifiiliniicd. 
Sinialn~c  is  a  n-adilv  ^ollllll<  mixiurc  nf  jirnicids  iircparcd  fnnii  infill,  and 
alnmsi    irc-i-    I'rnin    |n|.l>in('.      Nulmsi     and   cucasin   arc  siiniliir   pr.].ar;niniisi 

made    I'r milk.      'I'lusc    pnudcnd.    nadily    sidiildc   siilslaiins    in:iy.    liy 

rca.-nii  ni'  tlicir  aliimsi  inial    laslidcssn>  — .  he   hi'.-hly  servirrahle  «  hen   aided 

in  aiiinuiiis  nl'  a  U  ti.-i t'lil  In  >nii|,s  and    he\era-,^.  |>:irliciilarly  In  patients 

\\\\u  have  a  ir|ini:nane(    tn  l  he  use  n|    i -l's. 

In  spile  nl"  all  llieoretie  nhjnciinii-:,  alCOhoUc  bevcragCS  are 
still  indi-prii.-alile  in  the  praetilinia  r  in  ihe  tnalmeiit  nf  lyplmid  t'ev<T. 
a-  well  a-  ill  till-  ireatnieiit  nf  aeiile  Tehrile  ili-ea-e-  in  L^eiieral.  It 
wniiid  he  sllpeHlllnii-  at  tlie  |in -elit  day  In  di-eii—  i'nriner  nlijeeliniis 
with  reL'^anl  tn  the  iiitliieiiee  nl'  alenlml  ill  ineiia-iiiLr  the  t'ever.  N'mi 
Ziem-^en.  .1  iirL''eii>eii.  and  l,ielieriiiei-ter  have  pennain  iilly  tiisposed  id' 
till-  |>reilldiee.  AltlinllLdl  the  tlienreti<'  e\  phll'alinll  is  (liiliellll,  ])ra(- 
lieallv  ihe  -limiilalintr  iiiiliieiic'e  id"  alenlml  iipmi  llit  eirciilatinii  and 
re-piraiinii  i-  e-talili-heil  lieymid  doiilii.  In  aildiiinii.  it  is  tisel'ii!  lor 
cnn-erxini:  waste  and  L^'nenitiiiir  eiierLT}'.  I  slimild  imt  he  willing:  to 
treat  lyplinid  patient-  at  all  in  eertain  >taire>  and  eniiditioiis  \vilh(ii:t 
aleiihnlies.  The  einplnvnieiU  nf  ah^nhnl  luitiirallv  rei|nin'-  strict  di^- 
eriininatinii  in  everv  ea-e.  In  ehihlnn  il  is  to  lie  avnided  ait<ii:etlier,  or 
tn  he  einplnved  niily  teinp(irarily  a-  a  last  re-nrt.  In  severe  ea.^es  in 
adults  I  |ierniit  tVnin  the  miNet  -niall  ipiantiiii-  id'  ,-pinliinii,-  drinks  to 
he  taken  Pirularlv.  nndiliiied  <  .  diluted,  keepin-  in  niiiid  flit'  consti- 
tntinii  and  ]ireviniis  hahits  nf  the  patient.  L'nidii.illy  inereasintr  the 
aniiiiint  with  the  ri-e  nf  the  fever,  ^are  stmnhl  he  taken.  a]tart  fr  .m 
aleoholie-.  not  to  ._rive  lai-LTi'  do-e<  at  the  heLriniiini:.  in  order  Hot  to 
jeo|iardi/e   the   po-ihility    nf  elVeetive   iiierea-e   in    time-   oi'  neee-sily. 

h  is  hesl  to  I'liiplnv  wine  and  slmnLT  spirits.  Kxeeplioiiallv.  heer  may  he 
used,  and  then  (ireferalilv  llm-e  varielie-  thai  are  rieli  ni  Imps,  are  well  fer- 
mented, and  rich  in  alenlml.  and  they  .-lioiild  he  L'iveii  only  in  small  amounts. 
Ainom:  wines,  the  red  rmrdeaiLX."  r.urL'iimly,  and  eld  Kliine  red  wines 
( Assinannshaii.sen   and  the  like  i  are  in   ■.'eiieral   to  he  ))referred   in  view  of 


-^^fc«»»  -^T^"    .>-*^'^-f^l 


Ti:i:.\TMi:.\r. 


451 


the  intestinal  altcratinii.-i ;  alsn,  white  IJIiiiie  wine;*  of  some  a<:e  are  usually 
well  liorue.  Some  |i:ilieiits  liear  soutlierti  wines — slurry,  |i(irl.  Maileira, 
and  'I'likav — alsu  some  Italian  and  (ireek  varieties.  They  mny  lie  admmis- 
tered  undiluted  nr  mixed  witli  natural  .S  hers  water  nr  e(dd  tea.  I  ndi- 
luted,  these  wines,  whieh  cdntain  t'nim  1 '_'  to  17  |ier  eent.  (if  alenhiil,  are 
eniploved  in  the  presence  nf  iiruirre.-sive  weakne.-^s  and  eondilinns  nf  euUapse  ; 
ami  in  their  stead,  nr  allirnatini:  "ith  them,  also  cham|)aL'ne,  care  lieiu;; 
taken  in  this  cuniieelinn  t.i  avoid  the  dislmneslly  pre|iared,  le.-s  valualile 
varieties  so  mmmon  at  tlie  present  day.  While  ordinary  white  and  red 
wines  eontain  from  7  to  >*  ])er  eent.  of  alcohol,  irood  hrands  ot'  ehanipaL'iie 
Contain  from  ID  to  10..j  per  cent.  If  tiiere  lie  any  reason  to  em|.loy  tlie 
stromrer  alcoholics,  eou'nac,  rum.  and  ante  may  he  administered  in  tea  or 
hlack  eoll'ee.  A  convenient  mode  of  a..miinslerin^'  eoL'nae.  liy  means  of 
which  the  dose  can  lie  well  reirulated,  is  in  the  form  of  the  widl-knowu 
Stokes  mixture.  'I'his  is  especially  avaihiMe  also  for  persons  who  do  not 
tolerate  alcohol  wtdl  ;  in  addition,  the  contained  eL'L's  appear  to  lie  easily 
dii,'eslil)le.  The  formula  employi'd  at  my  clinic  consists  of  slroiiLT  cuirnao 
50,  volk  of  egj;  1.  svru[)  of  cinnamon  I'd,  distilled  water,  sullicieiit  to  make 
loO.' 

DIET  DURING  THE  PERIOD  OF  DEFERVESCENCE  AND  THE 
STAGE  OF  CONVALESCENCE. 

It  lias  alreadv  heeii  seen  that  in  many  patients  the  appetite  heLriiis  to 
return  duriiiu:  the  -taire  nf  steep  curse-,  and  alnio-t  always  and  in  still 
greater  dcLrree  after  deler\('Seenee.  I'lle  de-il'es  (if  the  patient  sluillld  l)e 
rcstraiiKMl  at  this  time  on  aeediitit  of  the  still  prccaridus  state  of  the  intes- 
tiatil  eaiial.  On  the  other  liaii<l,  one  slmidd  Udt  he  altdi^ether  tud  timid, 
as,  if  the  restrietidii  in  diet  1k'  too  hmt;  •diitiniled,  cdnvaleseence  and 
the  resnni])tidti  id"  funetioiial  aetixity  may  1h'  unduly  defi  iTed.  Kveii 
(lurinij  the  stajri?  of  steep  curves,  especially  if  nietedrisni  ln'  not  present 
<ir  antecedent  syniptunis  of  iieritonitic  irritation  or  lienidrrlia^e  does  not 
adniduisli  especial  cautidn,  I  pernut  the  additidii  of  sdii|>  to  he  taken 
in  eoiisiderahle  aiiidiiiit,  (ir  the  earlxihydnite  articles  of  fd(Ml  to  he  eaten, 
even  in  the  feirm  df  a  thin  iiajt.  In-t.ad  of  ejrs-''s,  swet^hread  or  hrain 
passed  tlironjjii  a  titie  sieve  may  Ik  addeil  to  son|)s.  These  ai'tieles 
must  sulliee,  witii  as  much  variation  as  possihle,  until  the  end  of  the 
first  afebrile  week. 

From  the  sixth  or  the  seventh  afebrile  day  I  permit  the 

first  solid  fddd,  iK'trinninir  wi^li  .some  zwiehack  or  cak';'S,  especially 
pastry  ])repar(Ml  fruiit  alenronat,  snake(l  in  milk',  tea.  or  cocoa.  Th^n  a 
soft-boilinl  vjrrr  may  lie  permitted,  and  linely  scniped  raw  tillet  or  salmon 
or  a  mixture  of  the  two. 

The  meat  is  scrapc'l  with  a  silver  spoon  upon  n  porcelain  di'*)),  and  for 
the  first  days  additionally  pa.sscd  throUL'li  a  fine  sieve. 

If  all   tlie.«e  are   well   ho....,   roast  yotine;   fowl,   sipiah,  chicken,  or 


i 


^v^^^^ 


-i'- 


IV. 


TYPIInlli    IIVI.I:. 


partri'lirc    iiiav  lie  Lrivcn.  at    lir-i    in   iIk    f'onii  i.i'  iiun'c  addccl  tn  ^dup  ; 

llu'ii.  tiiicK  iliviilcil,  \villii'UI  lal  SHUT.       At  llic  siiiic  ti ir  m",ii  at'l<T- 

waril.  iiia-liril  putatiM'.  i.r  well -stirred  iin,  ami,  witli  the  iiicat.  -<iiiic 
crii-t  lit'  pill  iir  liia-l.  iiia\'  al-n  lif  |»'riiiitlril.  'l"iii-i-  artii  ir-  iiia\  -niiii 
lir  liiljiiwiil  li\-  liulil  li-li,  f-|i('i'ially  tfiiiit,  Imilcd  in  -all  water.  .M'liT 
tlii-.  -i-rar  il,  -lii^lill^  nverilniie  tillel  inav  lie  'ji\en,  ami  all  tlie-i'  arc 
I'l  lliiwid  at  llie  em!  lit'  tlie  -eennil  or  at  the  11.  ■jinniiiL''  "t"  the  third 
afebrile  week  \>\  lnnilicl  lean,  temli  r  ]iieee-  ul'  meat,  \tal  nr  iniiliun 
entlet.  ami  tillet  nt'  lieel'-teaU,  vnuii'.'  ijaine,  liaiv,  nr  deer. 

Ill  tlie  ei.nr-e  111'  tlie  tliiril  week  re-nrt  inav  lie  had  tn  lijlil  vcLfeta- 
lile-,  a~|iarairu>-ti|i-,  ^iiinaeh,    |iiiree   nt'  trreen    |iea-,    earrnt-,    artiehnkes, 

and  the  liki.  JMirl.ii:  the  sccond  and  third  weeks  of  convales- 
cence it  i'  neee~~ar\  til  ai!niini--ter  timd  at  least  live  limes  daily  ;  sniiiu- 
tliiiiir  slmuld  lie  |iriitl'ered  tin  patient  excn  diirinu'  the  iiiL'hl,  it'  he  is 
awake,   sneh    a-    milk,    eake-,    and    the    like.       In    addiliuii,  all   surt-  nf 

trilles  ^hl.nld   lie  ij-ivi  II    the   [latiellt   ihirillir    thi-    Jieriml    lielweeii    till'  |irin- 

ciiial  meal at  tir-t,  wine  i.r  meat    ji  IK  ;   it'  rediieed.  eaviar  nr  ii\-ter<; 

the  I  la  til  I  It  will  lie  Lrr;iiet'nl  al-n  t'nr  apple— .iiiee  ur  i  it  her  tiirni-  nf  ~le\\ed 
t'riiit  that  are  nut  tun  -weet.  I 'nennkeil  Iriiil-,  Imwcver,  shmild  he 
withheld    t'nr   a    InliL''    time. 

The  ilietelir  reju lalii ni.s  previiiii>l_v  meiiiliiei'il  will  iiiitiirally  serve  (inly 
as  a  u'eneral  irai'ie  ti.r  the  .-ii|ieiliiu>  |ili\^ieian.  I'nuii  uliirli  he  uill  arranire  a 
(lietarv  in  aeeiirilame  wiili  the  ]iatient  and  the  rliaraeicr  ami  the  >t;iL'e  i if  the 
(liseasi\  While  ui'  niu-I  reipiire  strirt  nln'ilieiiee  iVmii  ]iatients  ami  ii>.-i>laiits 
with  reL'ard  In  llie  diet,  their  iiistruetinns  ^Imulil  he  L'i\en  in  a  clear  and 
well-detiiied  niaiiiier.  1  )uriiiL''  the  rritieal  iierimU  cf  the  (lisea>e  it  is  wise, 
ill  iinler  that  im  (liti'crence  nt'  (i|iiniiiii  iii.'iy  arise  hetweeii  the  patient  and  the 
iiiirse  and  the  t'aiiiily,  that  the  ilaily  in>trnctiiiiis  with  reirard  In  diet  he  given 
in  ilet.iil   in  wriiiiiL'. 

d'lic  niiide  if  treatment  de-crilied  in  the  fnrciroiiii:'  is  nftcn  (Icsii^iiated 
"  exi>c<taiit,"  hut  witliuiit  priipriety.  it  has  heeii  st'cn  that  the  attitude 
of  the  pli\-ician  i-  anythiiiL^  Init  e\|icelaiit  ;  lint  t.iat.  nil  the  eniitrary, 
lie  i-  tiillv  and  m  i-t  re~pnii-ililv  ncciipicd  with  carryinir  nnt  the  treat- 
liienl.  <  >tie  inii-t  'Z>>  even  t'lirtlier  and  say  that  fur  the  mild,  imiderately 
severe,  ami  e\en  Inr  a  mimlier  nf  -  \ere.  iinentnpiicated  ea.MS,  partieid.arly 
in  prc\iiiii-lv  healthy  indi\  idiiai -.  the  dietetic  treatment  and  careful 
sn|>crvi--iiin  citherwi-e  render  -iiperthinii-  e\cry  other  niea-nre.  Fur- 
ther thera])entic  intervcntinii  will  I.e  necessary  only  if  the  course 
of  the  attack  Im'  -cNcrc  or  iimi>iial.  or  in  the  presence  of  alarniin<T 
conditiiii-  villi  reference  to  certain  ^y-tenls  or  oruan-;,  whether  rcjiro- 
scntinir  |ieciiliar  loc.ali/.alion-  of  the  tyjihoid  pnwess  or  actual  cninplica- 
4:,...,:       j).,^};,...]..^  .'ittcntio!!  has  always  lH*n  L'iven  to  the  fever  ill  thi.s 


i^ 


ff=f 


-.T^3l^.;i«*ftL«f: 


TIIEATMKST. 


45;{ 


connt'ctioii,  ami  tin'  l;i.-t  tliirtv  vturs  i'.~i>i'<i:illy  liave  \vitnc.--(<l  the 
as-Ill. i|)tiuii  dl"  lir.-t  plaw,  practicallv  and  tlnoitlii-^illy,  of  tlio  iiitlL»idri 
of  treatiiU'iil  iiiiiij>iilirii(l(<l  iiii<l<r  tlu^  dc.-i^'iiation  aiitijiyrLtii'. 


THE  SO-CALLED  ANTIPYRETIC  METHODS  OF  TREATMENT. 

Earlier  and  Present-day  Methods. — Kvtn  at  tlic  jin-dit  day 
tliiif  is  still  aliiindant  roason  for  pviiij^  fsju'cial  aitciitioii  to  anti(>_vretic 
liu'tlio<is  ot' trfatmciit,  l)iit  tin.  pri-ciil  ^lalldl^oiIll  aifMi-dfd  l>y  the  reccut 
results  of  ctiolo^.ric  iiivcstii,Mtion  i-  <|iiilf  dillriciit  from  the  fornur  one 
Tlie  svinptoin-i-omplcx  dcsiirnatcd  ftvcr  may  \»-  con^-idcivd  in  the  main 
as  ;iii  cxpn-Mon  of  tlic  action  of  the  typlioid  toxin  n|)oii  tin-  tis.-ncs  and 
niclaliolism.  Tiic  sole  rational  inctlKxl  of  treatment  for  fever  would, 
aeeordiii>.rly,  consi-t  in  neutrali/iii'_'  the  vitid  manifestations  of  the 
baeilli,  and  partieuiariy  the  toxic  etVeets  to  which  they  trive  rise.  As 
is  well  known,  we  are  still  far  frotn  this  poal. 

Altlioujih  for  a  lonj;  time  one  of  the  most  eonspiciious  symptoms  of 
the  fever,  the  elevation  of  l)ody-teinporaturi>  was  looked  n|)on  as  the 
most  deleterious,  :ind  therefore  the  most  worthy  of  attack,  and  hy  some 
is  still  so  considerol  at  the  ])resent  day,  this  view  is  no  longer  tenahle 
in  the  ligiit  of  current  conceptions  reirarding  the  nature  and  mechanism 
of  the  infectious  |)rocesses.  Our  present  treatment  is  directed,  on  the 
whole,  toward  reiiderinir  the  etlects  of  the  toxins,  which,  as  has  heen 
noted,  I'annot  he  entirely  prevented,  so  tiir  a<  pos^il>le,  innocuous  for  the 
patient,  and  toward  sustainiii«r  his  powers  of  resistance  until  the  infec- 
tious process  has  spontaneously  exhauste<l  itself.  Altiioiiirh  at  present 
much  less  imi)ort;ince  is  attached  to  <liri"t  control  of  the  elevation  of 
temperature  than  formerly  was  the  case,  we  do  not  go  so  far  as  to  ignore 
this  entirelv,  nor  do  we  coii>i<ler  it  as  the  i/'x  imdiratri.r  iiatnra-,  and 
therefore  not  to  l>e  iiiterfere<l  with,  as,  owing  to  the  revival  of  old  theo- 
ries, is  lielieved  at  the  pre<eni  day.  On  the  contrary,  it  must  he  atlmitted 
that  nnii-ually  high  tcmiteratiire.  especially  if  maintained  for  a  long 
time  and  at  a  uniform  level,  may  in  iI^elf  he  attended  with  serious  evils, 
viz.,  aei'elcratioii  of  re-]iir;ilion  and  pulse,  aid  jirohahly  also  increase 
in  jiroteid  disintegration  aii<l  in  the  oxidation-processes  in  general. 
However,  in  cases  of  iv|)hoiil  fever  this  is  practically  to  he  taken  into 
eon-ideration  in  far  le-s  deirree  than  in  connection  with  some  other 
infectious  diseases  ;  l«'cause  in  cases  of  otherwise  severe  typhoid  fever, 
even  (luriui:  the  i'a-ti'jium,  the  e)ev:itioii  of  the  hody-temperature  is  in 
general  eoiitined  witliin  moderate  limits. 

Although  we  are  thus  iinahle  to  sliare  the  view  of  those  who 
judge  of   the  fehrile  process  principally   from  the   state  of   the   ther- 


¥12 


454 


TYrii'iiii  1 1  \  ill. 


IliltL' 


niiiiint(  r,  ail"!  ;is  a  runiiiic  juimi  iliiic  aim  at  ndiu  liun  ul"  tlio  tcinjMTa- 
tiirc,  we  -till  liilicvi',  ncMillirli  — ,  ihal  irua-iin  -  iliin  icil  (.1  ilir  n  lii  1" 
(•I'  llii-  -\  iii|ilMni-i  "iiilili A  a-  a  \sh"li',  alnl  lluftliv  I"  lli''  I'l  Hi  I  o|'  u 
imiiilii  r  I'l  ili-lniliaiM>  -  wli^-i-  inailviil  ilivclnjiriulil  aiiil  |in>li>ii;rc(l 
(luralii'ii  ma\  lncnrur  a  .-niirir  nf  iLmu'ii'  I"  'ln'  iiaticlil.  ai'<'  "Hi  11  iinli- 
ralcil  aii<l  olU  11  (  <  >ii-.|iiuir  an  ii:i|><M'lalil  |'ail  nl'  tlu-  1 1  <  aliiiclil.  I  lie 
ili-liirliaiiii-  jirc.-iiii  arc  (-|iiilally  llii>-f  ri^iiltiii^  Irniii  llii'  arlioii  <.!' 
till-  t"\iii-  ii|H.ii  \\{.  rriiiral  iiii\"ii~  .-_\  ~l(  III.  am!  c'l.n-i-i  in  tin  i'.  him'- 
(jiniil  .~lali  -  I'l'  .-M|»i|-,  (I  ma.  cliliriiiiii.  ami  ]ir(i|iiiiii'l  iiivulvciiirrit  of 
tlic  liio.-t  vital  (1  iiliiai  itnti  1.-.  (-|i»riallv  tli".-f  I' li -|iiral  i"ii  aii'l  cifcu- 
latioii.  ami  uii.iii  wliirli  ai-.i  Kftaiii  di-i'idcr-  ui  the  dii^r-tive  iTLMtis, 
of  till'  miliars-  -n  iii  1011-,  and  ul'  tlir  I'liiiri i'  ii-  nl'  tin-  iiiii-rii-.  are 
ilitiinalilv  ill  piiiili  111.  Tliat  liy  (i.ni  ■tin;:  tin  rniicliniial  ili~tnrliam'i'S 
(•f  thr  ,-v-lrii!-  ami  iM'L'aiis  in  (|m-lii>n   tiir  ii"ii_\    niav  lie   niiilcffil   iimre 

rc-i-tant    til  (Airi-iial  niutiiid  intliU'iicc. tliat  i-,  tn  the  (Icviliipiiiciit   nf 

conqiiifatiini ami   tliai   at    tlic  saini'   tinir.  apart   IVmiii   tlic   iiniiuHliatc 

indication-.  ]irii\  i-imi  rii:i\  It  madr  I'm'  llir  rmiirt'  i-  a  i'lirtliir  olijrct 
of  till'    ailliliyi'ilir    lIH'llii'd    I'f   trralniriit. 

l-'riiin  till'  iiirt  "jiiiii'j-  ii  I'mIIuw-  that  tlir  limit-  nf  tlic  aiiti|iyrctic 
ini'lli'id-  of  trcatnicnl  aiT  at  tin  pn  -iiit  day  in  many  direction-  more 
<'\tciisivc,  and  in  oiIh'I-  K  .--  .-o  :  nmrc  cMiii-ivc  in  -n  iiir  a-  wc  do  not 
attcmiit  to  ."ittack  a  -iiiLdc  -symptom.  Imt  an  entire  L'l'oiip  of  .'^cverc  con- 
S(>i|iienec-  of  the  i iiii 'X ieat ioii.  and  tlii-  inetlii'd  of  treatment  i-  tliercfore 
tlioiiijlit  to  lie  indicated  imt  mdy  when  the  ti'ni]ii'ratiirc  rcaelK-  a  liijrh 
level,  lint  al-o  when,  a-  .-o  ot'tcii  lia;i]icii-.  the  intoxication  is  most  mani- 
fe-t  with  a  h'W  IhmK -tenipciatnre.  or  when  it  i-  scarcely  clcvatcil  at  all  ; 
],.ss  eMeii-i\'c  in  so  far  as  the  imlieation  f  ir  amipyreiie  treatment  is  no 
lonL'i  r  looked  tiir  in  perfiitict  ry  manner  in  every  elevation  of  hody- 
Icinpei-.itiire  atiove  a  ceilain  deirrcc.  liiit  jirineipallv  in  profound  dis- 
ttirliances  of  the  central  nervous  .-y-tem,  the  circnlation,  :!!id  the 
ro-piralioii.  in  eonsc(|iienee  of  which  tli  '  larp'r  immlicr  of  mild  and 
niodcratelv  severe  ea-es  are  not  siil)j>'cte<l  to  aiitiiiyretie  treatment. 

With  the-  i|ualiticati  iiis  flio  antipyretic  methods  of  treatment  may 
now  lie  di-en--ed.  Ilvdrothernpy  may  he  looked  upon  as  its  most 
ctViclent  and  nio-t  imiiortant  form,  while  the  employment  of  the  so- 
called   anti])\retic   medicaniciits   are   mneh    less   iiscil   and   esteemed. 


?&^^" 


HYDROTHERAPY. 

Historic. —  As  \Vith  the  main  principles  nf  dietetic  iiianaL'enient,  we  are 
maiiilv  inilehted  to  I'aiL'li.-ii  physicians  for  tlie  priiici]iles  nf  hydrotlierapy  also. 
It  w.is  first    eniiiioved  .svsteiiialieally  iu  typhoid   disea:^os  toward  the  end  uf 


ri:i:M  Mi:.\i: 


455 


the  iML'litiiiitli  <'fiiliirv  liv  till'  l.i\iT|HHil  |ih\  >i(i;ui,  .laiiic-  Ciirrii  '  He 
USimI  \\:ircr.  |)|-iii(ip:ilU  in  llii'  I'liiii  "T  <-'>l'l  ilmirli.-.  ;il  truiii  .1  |o  ll»  ( '., 
jjiviiiL'  ilii-Mi  L'lMnTiillv  tuici-  iliiilv.  Ik  ■.'iiiiiiii.'  al  an  larly  |.irii"|  nl'  tin-  ili.- 
ciisi'.  Mr  U.I- SI  Mill  itiiitali'l  IpV  iikiii>  |iIi\  :-i''iaii.-  in  all  I'nmitrifS.  en  lliat  in 
till'  thinl  eililioii  uf  hi-  l""ik  lie  was  ulili-  tu  n'|inrl  luiiiitTipii.s  <'iiiitirrii:iliniis 
lit"  111-  >ii(  .'I'-s  in  his  iijiiili-  nl'  iiriH'i'ilurr.  T inlniilitcilly,  ('iirrii''s  stalisiics 
a|i|ilv  tinih  111  lv|ilius  ami  I"  Upliniil  ti'Ver,  uhii'li  at  that  tiiiif  cihiIiI  imt  Im- 
llioriiiiLrhlv  iiiirrrriiiiali-i|. 

Kruiii  ( 'iirrii-'s  i|iiii'hi-s.  whii-li.  wen-  fur  !i  luni;  tiiiic  aiilicrt'il  to  in  France 
as  aim  i-l  llir  sulr  ini'ihul  liv  ilir  iiiusl  ili-tinL'nislicil  |ili\  sirians  >  Ucraniliier, 
'IVuiissiMii.  ('Iiniinl.  anil  (  liirniicaii  lie  Miissy  .  llicre  iIi'VcIi>|>im1  ^rrild- 
iially  ihi'  niiMhinl  nf  ti-iatnimt  with  riiM  liaihs.  In  I'Dinliinalidn  with 
thr  iiiHirhi-s,  aiiij  also  varmuslv  inoiiilirl  in  othi-r  rcs|ii'r|>,  tliry  wen-  cni- 
|>|oVf.|  cxirnsivi'lv  11H  liTinanv  in  tlif  tirst  tv\o  lici'ailcs  nt'  the  iiinftemth 
I'l'iitiirv.  anil  sunn  luTann-  so  hi/hlv  csifiMiicij  that  out'  of  tlif  iiiosit  cntliu- 
siastir  ailvocati's  of  h\  ilmllifraiiy,  10.  Horn.'  ilcsiirnalcil  it  a.s  the  only 
tisi-fiil  ini'thoil  ill  ihc  iriMtnii-nl  ot'  ty|ilioiil  f.'vt'r.  Ncvfrthclcs.s,  the 
pron-liin-  «a-  not  ji'iiiTMlly  aiio|itiMl.  .\ Uhoiii.'li  -till  |ira<-tis<.Mi  liy  some 
^von  (iictl.  Ninni'viT,  'rnnilii-.  A  nnitaL'c.  (Ira\cs  .  it  ^.Tailually  U-ciiinf  liis- 
placcil  liv  ri'rtain  nii'iliianal  nn-ihoils  anti|iyrrlic  ami  aiiti|iutrffai'tive.  In 
(Ifrnianv  it  was  roviv«'il  \<\  !'..  ISrainl.'  of  Stettin.  I'o  liini  lielontrH  the 
cririiil  of  liavin,'  ilcvi-loiitMl  anil  .applicij  ilic  proi'cilurc  inctlioilically,  an<l 
tlirrrhv  of  having'  L.'ivi'ii  the  -imiiiliis  for  a  new.  perniantMit,  anil  stl(rcf.sst"iil 
iiiovcnirnt.  .\s  the  leailers  in  this  who  has.'il  iheir  elinieal  exp<Tiinont8  and 
oli-ervalions  upon  the  prevailitiL'  conieiition  of  the  lyphoiil  priK'ess  and  ')f 
the  )■■''/'•  plavel  l)V  elevation  of  tiini>eratiire  in  t'ever.  .Iiirtrensen.'  Lielier- 
ineister  ami  llaLrenliacli,'  /ienisseii  ami  Inmicrinann  "  shouhl  he  nieii- 
tioneii.  In  Krame.  (ih'nanl  I  "^T'l  1.  of  Lyons,  introiliieeil  the  method  into 
practii'c.  ami  after  him  espeeially  Fereol  and  Keyiiau  ;  then  Heiiay,  Tripier 
and  liouverel."  and  oiliers.  The  method  soon  heeaine  |>opiil!ir  also  in  the 
remaining;  eouutries  of  the  continent  of  Kiiro|>e.  and  also  in  England  and 
America. 

Various  Methods  of  Employment. —  i'ln    methods  nf  apply- 

ilii;   water  are   extreliielv   diverse.      <  )ften    sume    iiioile-   have   l)e<>n   lii-- 
fended  with  j^reat  p<r-isteiiey  as  aimie  iiseiiil.      In   addition  to  the  ciirly 

'  M,,l,,;il  /;■■,„, rti  nil  thr  l-'tTrrt^  ..f  W'^iti-,-  nx  a  finrfih/ /..r  t'rri-r.  etr.,  Lenilen, 
17'.)".      (iiriiiiin  truii-lulion  I'V  Mii'liiieli-.  I-.ip'^io.  1801.      ('(impure  the  lii-turic  deserip- 

tiuTi  of  Ihr  ili'M-l'i|imi'iit  I't'  till'  iiietli.iil  in   Kiej-liUHJ  nii.l  Friinri-  in    Miirclii-nn',<  1 k, 

from  whii'li  nm-t  -uh-i"pii'i't  writer-  h:ive  Iiikin  llnir  liiitii. 

'  hyfafi ruii'lin  u'lrr  </n-  li'-hmn  i//-v  njisfrrkrriiini  .\rrvn-  utiti  Ijiznrrthti''hfrs^ 
Berlin.  lf*14. 

' />(>  llifh-'thr-riip:i-  ilri  T'.i'liiix.  Sti'ltiii.  ISi'.I,  /,/;■  }lwlruthfrapie  i/rn  Typhus, 
Stettin.   ISCi'.'.      I)ir  llrilniHi  (le«  Tii/'/i'is.  liiTlin.   Isi'.s, 

*  Klin.  Sf'/'frrn  uhrr  'fir  Hrhnndhniij  ties  Ah<inininaltv}>ftits  miftcht  liry  kaltfn 
W'mtsmi.  Li'ip-ic,   IStlii 

■^  Jirnhiv'htini'i'  :nJ  Vrr^in'hr  uhrr  tiir  Ainrni'iiiiiq  i/rt  knltrn  WnHsrrx  hri  fjeher~ 
hafti-n   Ki-'inl.hrilri,.    1,1  ip-ie.    IXi'.H 

"  Dir  h'fillir'ixsi'riirh'iil'iluii'l  i/r.s  Ti/jthusnh,l"mninri<.    I.eipsie.   187^. 

'  I,:i  fii'-vrr  fiiph'.idr  tr'iifri-  pnr  hs  h.iiiis  //■■■'ilx.  Piiris.  IS'.KV  Tlii- I'lireful  nrtiele 
is  ha.seil  up'iM  ;i  liirje  nuinlipr  nf  I'u-is.  iirnl  ii>ii>;tinili'!;  the  bp?t  description  nf  the  di'vel- 
opnu'iil  inid  tin-  jiri'-ciit  status  nf  the  ipie-tinn  in  J'rance. 


1.^    I  f    »   v\- 


.-^"'V'j-  ..•t*J':*7^^-. 


ni^' ^^k^%:i^y?^^^ 


456 


I  )  riioih  1 1  lit: 


llfnlfll' 


(luiiclir-  nf  ( 'iirrii  ,  :it  llic  |iii-(iit  iliiv  -|".ir_'iri'_'-,  tViitii'ri-  willi  culd 
\\;ili  r.  "T,  ;i>  i-m1iii'i-i  iiiii\  ci-.iIK  >  u-lMHiarv  in  I 'r;iiii  c  iiiid  in  |-,ii;j  l.iml, 
wilil  \  llii"jll'-\i;ilcl-,  .irc  |ir:iill-iil  ;  lilllljii.  \m  l  |i:ii  k-  ..t'  \al\  iiii;  li  Iii- 
|iiT;iliin'  nnl  i|iil;ili"ii.  |Kii'li;il  I'rlri'ji  r;ii  ion  |,\  riicMli-  ol  iiHii-inii^, 
till-  1 1-1  i.r  Wall  r-li;ii:~  lllli  i|  Willi  ■  "|i|  \\:ilrr.  In  ,  ..r  i\i  n  culil  iiii\liirr-, 
liall'-lialli-  Willi  tViition-  ■•!■  iImii.Ih-  (a-  wi  ii  iicmmiiik  nili  il  l.\  Uraiid 
in    lii-    tir^l    piililiralinn  i,   aiiii,   linilK.    t'nil    Kalli-    >  '.'  inn-t    \ai'i<il    kiml. 

Treatment  by  Baths.  -  lull   l.atli-  aiv  ai   tin    piv-.  m   day  liv 

I'ar  ino-l  iniiiini.Tily  u-cd  ;  wliilr  iIh  ..ilirr  im  llmd-  ar>'  iiim.||\  irii|i|i  im  il 
as  aii\iliar\  iiiia-iin^  >>v  a-  jiartial  -iih-liliili-  wlnii  haili^  caniini  Im' 
il-iil  nil  aiciiiinl  ■■!'  iiidi\  idiial  ■•!■  r\l  ram  nii-  ii  a-nn-.  \|  til>l,  ninli  r  llic 
jirulcHiiul  inlliniicf  ..I  till-  lali'.r-  i.|  Ilrand  and  lii-  -iiri(~-nr>.  and  in  i-nii- 
."(■(juini'i'  Ml'  u\  tn  -liiiialiiiii  (•{'  ilic  -i.jniliiaiicc  111  trill  ilr  ilcvaliiili  of  Icin- 
jxi-alnii',  ■■iild  lialli-  wi  ic  jint'i  laliK  t'ivin  at  Iriii|iiralnn  -  a-  \>>\\  as  tVuiii 
♦)  to  In  ('.,  and  llic.-f  were  warmly  ad\i.ratid  at  W  iisliadiii  '  as  late  as 
IMML'.  In  iiidcr,  so  tar  as  [m.-sililr,  to  avoid  tlif  -npiio-cdiv  <li  Ictfrious 
ovcrlifatiiitr  of  till  lilood  and  tlir  li--ncs,  a  Katii  ihii-  iM'i-ainc  ii(c<--sarv 
wlicncvrr  tilt'  tc'iniitraturr  reached  a  rcrtain   li\id — L'liicrally  aliovc  .'l!l° 

(ir.'i'.i.o-  ( '. o  that  tlir  piti-nt    not   rardv    nciivi'd  tVoin  ten  to  tii'lcfn 

fold  liatli-  in  tlw  ■  iiir-c  o|'  i  wiiitv -tour  lioiir-.  It  wa-  mtircU'  ovit- 
lookrd  in  llii-  coiincriion  that  rot  and  ( i|Uaiiiniit\  air  not  li-s  inijior- 
tant  till  rapriitic  t'aitor-,  wiiicli  camiol  lie  disniranlid  with  iiii|ii.iiity. 

Mo-t  jilivsiiiaiis  have  at  tlic  pn -tin  dav  n  luinrd  to  Ic-s  radical 
nicfliiKl-,  I'cr-oiialh,  I  -till  iinplov  \  crv  cold  lialhs  onlv  cxci  ptionallv. 
Ill  L'cncral  I  content  iii\-clt  with  lukewarm  liaths,  and  with  e-pecial 
pret'iTcnec  for  tlm-c  that  are  L'radiiallv,  and  then  iisiiallv  hut  moileratilv, 
(•doled,  -iieh  a-  Von  Ziem-seii  has  introduced  in'o  practice.  li'  one  do'.'; 
Hot  vet  Iviiow  the  ]>atient-  with  rei:ard  to  their  -n-ceptihilily  to  lixdro- 
therapeiitic  tiiea-nri  -.  they  are  fir-;  placed  in  a  full  liatli  at  a  teinjicratiire 
of  from  .".I  to  .;l  ( '.  l*erhap~  tin  fir-1.  hut  (.nlierally  the  second, 
hath  max  lie  cooled  to  L'T  or  '!')'  ( '.  li\-  the  LTadiia!  addition  of  cold 
water.  The  ii-e  of  wat'r  .it  a  tempcraliirc  lulow  '2-  (  .  i-  rarely  iiidicate<l. 
The  liaih-  are  al  lirsi  of  tVoiu  ten  to  fifteen  iiiiniite-'  duration,  and  siil)- 
seipieiitlv  all  i"\teiiiliil  up  to  tweiitv  and  e\  en  thirty  luiniitc-,  the  latter 
I'-peciallv  w  hen  the  -  ho  rter  duration  vie  Id-  oiil\-  -lichi  and  iioi  persistent 
filccts  ii|)on  the  ceiilr.il  nervoii*  -y-lcm,  the  piil-e,  and  the  re-piratioii.  In 
ca-es  in  roliu-t  yoiiiii:  iiidividuai-,  if  stupor  ■.uid  coiifu-ioii  ari'  iiiarkeil, 
colli  -poiiij-in'js  or  cold  douches  to  the  head  and  hack  are  associated  witl. 
tin  hath.  riie-e  nia\  he  pr;icli-ed  several  tiim-  in  the  cour-e  of  the 
same  hath,  or   hiit  once,  r.hortlv   hefore   it-   termination,   in  accordance 

'  Cum.   I.  uiil.    M.d. 


TlilMMFST 


457 


witli  tlic  cliar.ii'tcr  nt'  tli«'  la-i'.  in  tin-  ium's  also  io  wliiili  the  ilcmclio 
is  \\"\  rtiipliiM  il,  il  i-  :iil\  aiil:ii.'i  III'-  In  cnvcr  til  ■  111  ail  nf  liir  palli  lit  with 
:iii  in -lia_'  r  willi  a  inld  iloili.  it  i-,  lidwrvir,  iiiiiii  rt-sarv  ami 
.sii|M  rlliioii^  tn  lia\('  till'  patiiiil,  wliili  in  liir  liati.,  ilriiik  injil  watrr 
al)iliiilaiiti\ ,  ill  iiiili  r,  a--  it  wiir,  to  cihiI  aililitiniialiy  tin'  iiilrrmr  nt  tin; 
1)1  Illy. 

<  iTtaiii  iji'tails  nIiiiiiM  lie  slnctlv  ruilnwiMJ  iii  llir  pracliral  a|i|iiirutiiiii  of 
th<>  iialli.       Till'  |ialifiil  slii.iiM  iii'MT  ;.'i'I    into  iit   nl'  llu'  lialli  una.-sist('il, 

evi'Ti  it'  till'  tiili  lie  |iiaii-il  at  till'  siilc  (it'  ill.  Mil.  lie  riUMt  aiv\u_v«  lie 
lit'lcii  ami  rarrii'l  liv  ll.'  :i|lciiiiaijt.«.  llu  lialli-v, atiT  sIidiiIiI  cover  the 
clu'st,  aliiiusi  li>  llic  iitrk.  anil  llir  wi'll-sn|i|)iirtt i|  patirnt  shoiilil  rt'inain 
((iiii'l.  ( >ii  till'  111  llir  hanil.  he  is  l'iiiiIv  riiMifil  |itr>isli'iill\  ami  llic  y,a.Wt  ip 
('.)Mstuiiilv  k('|it  in  111.  vi'Miftit.  Diliilitalcil  i'uliviihials  may  lake  tniull 
iiuantitirs  ut'  alcnlml  — ir  i  with  cii'.'iiar.  port  w  iiu',  or,  with  aih  iiilau'c,  Stokt'8'?« 
niixtiiri'  liit'ort'  ami  iluriii;.'  the  I'linrsc  nt'  tl'p  hath.  .M'ttr  tiic  hath  all 
paticiil.s  shmil'i  ri'i'cive  sin'h  stiiiiiilaTits.  .\t  the  I'om'liisioii  of  the  liatli  the 
patient  slimilil  he  ilricil,  always  in  the  rciunilH'iit  posture,  n|Hin  iin  alternate 
heil.  anil  ilelirale  patients  slionhl  he  itrinl  lieinath  a  woollen  hlanket.  They 
should  then  hi'  kept  in  lieil,  snitahlv  hut  not  too  heavily  covered,  and  the 
utmost  quiet  alimit  them  should  he  maintained.  It  is  aL'reeuhle  ami  advaii- 
ta;;eiinn  Id  .some  patients,  as  von  Zieiii.s,sen  especially  ailvi.st'd.  not  to  he  dried 
at  once,  hut  to  he  permilted  to  lie  i|uietly  and  to  sleeji,  and  to  have  their 
clolhini;  cliaiii,'ed  oiilv  suli.-cipiently  on  awakiiiL'. 

In  private  practice  the  tuli  is  kept  in  tin  room  coiisianfly,  at  the  side 
of  the  hed  of  the  patient,  while  in  the  hospital  it  is  j;enerally  |iorIahIe,  or 
often  the  patient  in  hed  is  moved  into  the  liath-room.  The  |iracliie  of  {)er- 
mittiiii;  the  water  to  stand  for  day-i  in  the  tuh,  and  of  iisiii^  it  for  se.eral 
(lavs  in  succession  after  warminir  it  hy  the  addition  of  aiiiount.s  of  hot  water, 
is  a  practice  that  sliould  he  stron;;ly  condemned.  This  wool'  make  it 
impossiliie  to  secure  the  iieci'.s.-arv  cleanlines.s  on  the  part  of  the  patient,  and 
would  certainlv  j.'ive  ri.se  imt  rarely  to  infections  dise.ises  of  the  .'^kin — 
furunculosis  and  jiiileLrmon.  In  adiiilinn.  the  daiii:er  to  the  attendants  from 
such  infi'Cied  water  is  hy  no  means  to  lie  u^  denslimated. 

Indications  and  Counterindications. — The  repetition  of  the 

hath  is  governed  less  hy  the  ranL''e  of  the  liiidy-teni()enitiire  than  hv  the 
symptoms  i-efcialile  to  the  ceiitnil  iiervnus  system,  the  jiiilse,  and  the 
respiration.  Mo~t  |ilivsiciaiis  at  the  prc-ent  dav  endeavor  to  avoid 
extreme  reductions  in  tenipcnitiire  liy  means  of  the  liatli.  From  the 
use  of  the  kiinl  desi'rilied,  the  sim|ile  lukewarm  liaths.  or  the  Zienissen 
flKlihiallv  cooled  liatli,  the  reilllclinn  ireiierallv  diH'T^  not  exceed  one  fir 
two  dcirrc'S.  In  trenef.d  this  may  lie  considered  as  ipiite  siitlicient.  PjVen 
ill  severe  cases  and  at  the  heiirlit  of  the  disease,  front  two  to  at  most  four 
haths  in  the  course  of  tweiity-li'iit'  hours  will  >renenilly  he  sufjicient. 
The  lukewarm  hath  (iVom  '!'>"  to  .'50"  (". ).  of  lon<r  (luratioii — up  to 
twenty-four  lioiirs — ha.s  heoii  warmly  r('conirneti(l(Hl  hy  Kies.  His 
%»iows  h.ave  Ix'cn   n.eei'tit<'<l   liv   A'liinussief  and,   AIa!!as'><'iu.  -as  wjll  as 


ri/i   •,■ ' 


4.>S 


TvriioiK  ii:vi:u. 


in 


m 


l)V  I'livcrriihl.  luccntly,  ilicy  liavc  \»fu  lii;:lily  ])^:li^»■<l  uIm)  by  Eicli- 
lioi-t,  ;i:i(l  tlicv  arc  llui'tlipl-f  wurtliy  nt'  I'lirllur  tri.il,  cii  accdiiiit  d'  tiic 
wide  cxiHTuiu-f  ami  the  rt'lial)ility  ci|'  this  writer.  ( 'a.-vs  (if  ^(■vl'l■(' 
(iii.-i't,  with  -\  iiipldins  el'  iiiii'iisc  ]i(r-i.-l<iil  intiixicali"ii,  -li.nild  f'niiii 
tlic  .iiil-rt  111'  .-iiliji'ctid  to  llic  liatli-trialnicni.  wliioli  .-iiuiilil  lie  irii\ cnu'd 
.-ti'ii'llv  ii\  till'  iiiiliraliiui-  |iri-i'nt  in  tiic  iiidis  iiliial  ca.-c,  ami  lie  cuiijuiiRd 
with  tiic  aii.\iliar\  iivciiiatic  luca.-iin  -  ]a'c\i(.u^ly  iih  iitii'iii  .  I  udcr 
.-lull  liiTUiii-Iaiici's  tin  hath-ti'iatiiiriit  caiiiint  lie  fcplaccd  liy  any  othiT 
iiu'asiirc,  and  it-  oiiii--i(iii  or  inad<(|iiati'  iin|iiiiyiiii  nt  i-  to  lie  (■(Hi.-idtR'd 
a  M't-ioiis  ini.-laUr.  Tin'  ciniditiMii-  arc  dillrrtiil  wilii  I'ci.'-ard  In  the  mild 
and  im 'derate! V  M'verc  ea-e-.  'I'lu  >e  may  nnt  iei|iiire  the  liath-treat- 
inenl  ;  diet,  re-t.  and  the  .-\>teinalie  rei^Milatinn  I'l'  tiie  ;•<  niaininu'  (MJiidi- 
timi-  are  here  L''<lieralK'  (|uite  -ntheic  in.  Shmild  exaei fhatielis  (lecur  iir 
iu'ereiu'reiit  r-e\ere  .-vin|iteins  ari-e,  hatii-  slmnid  Ik  j.'-iven  al-<i  ill  tlu'sc 
ca-cs  at    \aryinir  interval-,    in   aeecirdame    with    the    exi-ting    eireuiii- 

Stailres. 

In   all  ea'^i'S  of  tyjilidid    fe\<r.  fnrtlier.   1   have   iri^eii  daily  "W.  |;  .s- 

>ililv   \\\'<.   I I   or   tepid   .-|MiiiL'int:-,  which    are   refi'e>hinLr  and   exert    a 

f,.4-.irahle  inlh'etiee  npnii  the  IK  r\iiii-  sy-tein.  in  in'>derale  and  ,-e\ere 
ea-is  an  iec-liajr  is  kejn  eMii-taiitly  ai)|ilied  tiMin  head  thr(iii;.'li"nt  the 
fclirile  |ieric"l.  \\'heii  the  |inl-e-lr.  (|neiiey  i-  hiirh,  it  i-  \seli  al-u  to 
ajiply  an  iee-hai:  hmt  the  heart.  .Marked  intestinal  -ymptimis,  es|ic- 
eiailv  inetenrisin,  demand  die  apiilie.itidii  <if  ail'iisidn-  to  the  aiidnmeii. 
II'  hroiiehitis  he  .sevefi ,  moist  ])ael-s  apjilied  to  the  thorax  and  <haii^'e<l 
ni't  too  freiiuently  are  of  jrn'at   adva!itaj.fe. 

Of  the  remainiiii:  livdrotheraiK'litie  mea-iire-.  to  whieh.  licAvevcr,  the 
prineijial  ;idvoeaIes  of  siieh  measures  atlaeli  -liudit  antipyi'elii'  value,  I 
iii.ike  little  use:  aiiionir  iheso  oold  packs  are  most  to  lie  recom- 
meni'eil.  For  many  ]ialieuts  these  are,  however,  tronlilesome,  ami 
espeeiallv  exhaustintr  if.  as  is  reeonimeiidcd  in  order  to  insure  tiieir 
C'tHeacv,  ihev  are  re]i<>.ite<l  everv  li<inr  or  two,  and  if,  in  addition,  cold 
vater  is  nsecj.  I  <ii-|»ense  entirely  with  tlie  ai)iili<'atioti  of  cold  secured 
l>y  filline;  the  water-cii-iiioiis  with  <  .ild  water,  ice,  or  even  cdd  mixtures. 
Whereas  caution  has  lieen  sevend  times  advi-ed  in  the  emiiloynier.t 
of  vii;orous  hathinLr-proeedures,  especially  \<'ry  <old  and  frequently 
repeated  full  l.atlis,  there  are  also  eertain  aiisulute  and  lelative  eontni- 
indieations  to  even  milder  methods  of  jiroeedure.  Every  form  of  hathiiifr- 
treatment  is  strictly  foiliiddeii  on  the  appearance  of  the  first  si^'n  of 
intestinal  lieniorrh aire,  as  well  as  on  the  appearance  of  even  the  sli^dilest 
deirree  of  peritonitic  irritation.  Tli-  imtiiod  is  also  danjreroiis  in 
patients    with   W(:;kness  of   the    heart,    especially    that    resulting'   from 


^yU^'^' 


m^ 


^O^rxt>iJi,^ 


TRE ATM  E.ST. 


459 


reocnt  mvoranlitis,  idocanlitis,  or  pericarditis.  Also,  jwrsoiis  with 
artiTiiisilcrosis  or  iiicoiiqilcti'lv  foiii|)tii>altd  vaKiilur  k-iioiis  of  wiiue 
staiKiiiiLT  an-  to  hv  ixviiuli d  t'roia  tiiu  batli-triMtnicnt.  I'liiiritic  ftl'ii- 
sions  oi'  (diisiileral)ii'  ainoiiiit  likewise  eoii>titiite  a  rii:i(l  eoiitra-indieatioii, 
wliile  ill  tlie  case  of  drv  jiicuri-y  and  |iiiciliiioiiia  this  luetliod  is  contra- 
iiidiciitcd  (iidv  if  tliey  are  a.-.>ociateil  with  wcaUiuss  of  tiie  heart.  I'hlehitis 
al-o  coii-tiliiIc>  a  coiitra-iiidicatioii  to  tiic  liath-trealnieiit.  I)itl'ii-e  hmn- 
ehitis  lira  teiidcncv  t  i  liv[>ostasis  of  ilic  iuiiu'>  i-  coiisidcriHl  in  myelinic 
as  a  special  indication  for  the  bath-trcatinent.  In  <'ases  iirc>entiiig 
severe  hirviiL^eal  legions  it  is  lie-t  to  omit  the  halh-treatment.  Snp- 
jMirativc  intlamination  of  the  middle  ear,  with  jicit'oration  of  the 
tympani'  inemlirane,  drmamls  L'rcat  care  to  ]irc\eut  the  entrance  of 
hatli-water.  Much  camion  -hould  he  exerci-cil  in  hatiiinir  pei-sons  who 
have  prcvi<in>lv  been  ill,  e-|>ecij|ly  tho-c  havinir  tiibereulosis  or  broli- 
chicetasis  with  a  tcialcnc}  to  hcmorrhatrcs  or  in  the  presence  of  inarke<l 
emphysema. 

Old  ajr<'  "dso  mav  consiitute  a  eontra-iiiili<ation.  The  baths  are 
generallv  not  well  borne  by  persons  above  the  aire  of  f.''y  yeiirs  ;  even 
of  those  pci'-ons  betwecM  tbrty  and  fd'iy,  oidy  a  sni:.d  mimber  are 
favorable  subjects  for  thi-  treatment.  In  children  the  balh-lrcaimi'ut  is 
in  general  less  commonlv  indi'atcd,  jioth  on  acconet  of  the  u-ually  iidld 
course  of  the  disease,  aiid  |iarticularly  by  reason  of  the  gi'ealcr  powers  of 
resistance  on  the  part  of  the  nervous  system  ami  of  the  heart.  ( 'hildren 
generallv  pass  (|uietly  and  safely  throi"rh  an  attack  of  ty|)hoid  fever 
without  anv  active  treatment.  Should  hydrotherajteutic  measures  be 
iudicate(l  bv  special  conditions,  particularly  those  involximr  the  nervous 
svsteni,  such  as  restlessness,  somnolence,  or  cenia,  lukewarm  bath'^,  with 
gradual  rp<luction  in  temperature,  and  douches,  in  accordance  with  the 
conditions  present,  will  almost  solely  be  a]i]iropriate.  Children  bear 
verv  cold  bath.s  even   worse  than  ailults. 

Certain  jthysiologic  states  of  the  body,  es|ieeially  the  ])ner]ierium, 
lactation,  and  menstruation,  do  not  eo;istitntc  absolute  eontra-indi- 
cations.  With  regard  to  tlie  constitution,  eldorotie  and,  in  general, 
anemic,  debilitate<l  individmds  are  usually  to  be  spared  forcible 
measures.  Great  care  .should  be  observed  in  the  case  of  obese  ]<er>ons. 
They  commonly  bear  hydriatie  treatment  jtoorly.  Hven  in  youthful 
persons  of  this  character,  particularly  in  "  bloonung,  thriving "  young 
wom(>n,  unfortunate  exjierieuces  are  not  rarely  encountered.  Such 
individuals  exhibit  a  tendency  to  weakness  of  the  heart,  which  b(>com<N 
nianiicst  nnex]iectedly  and  in  an  alarming  degree,  especially  after 
freipient  cool   baths.      The  gr.    t   teiuleucy   to   cardiac   weaknos  often 


460 


TYi'noii)  ii:vi:n. 


)-S 


.,->  - 


! 


t  wm 


reiulors  tlic  l):it!is  (laiiiri'i'niis  al^y  lor  altdlidlios.  That  there  are  also 
pnviiiii-iy  .i|i|iar(iitly  litalthv  imtmiiis  \v1ii>.  wIvm  attaikcd  witli  tvphoiil 
liver,  <\i<  iiipt  lirar  thf  ha'lis  well  and  lifiiiiiu'  markedly  hmtrtiid  and 
fxliau-Icd  in  ciin-ciiiifiicf,  is  a  notiwui  i  iiy  (■nl.  ( )!' the  .-cvcral  varieties 
ol'tyiiiioid  I'lVrr.  only  llic  nirc  h(  in(irrl;:ii:if  \ari>ty  rcallx  dcinaiid.s  care 
with  regard  tn  liydriaiic  incasuris. 

ANTIPYRETIC   MEDICAMENTS. 

The  Value  and  Action  of  Antipyretic  Drugs Antipyretic 

dnij^s,  wiiiili,  cvcti  at  the  hcifrht  of  the  hatli-trcatnicnt,  were  contmlfred 
hy  tile  niajiirity  ut"  jihysicians  as  less  inipnrtaiit  tlian  the  hiltiT,  tii-<lay, 
in  -pitc  of  their  ahiinst  daily  inerea.-iiiL''  nuinher  and  oiUn  warm 
endur.-enu'iit,  play  a  niinur  rule.  The  nature  u|'  their  L.thienee  nj)()n 
the  t'levati<in  of  temperature  is  still  in  dis|)ute,  and  a]i]iarently  is  not 
the  same  lor  the  ditlerenl  remedies.'  Evidently,  none  of  them  exerts  a 
s|M'eiti('  influence  u]ion  the  morhid  process,  and  therefore  the  antipyretic 
effect  i^  not  ai  all  com))aral)le  to  that  of  (piinin  in  the  presence  t)f 
malaria.  A  favoralilc  influence  upon  the  central  nervous  system,  the 
]>ulse,  and  tiic  re<]iiralion,  whicli  is  coiisidcred  as  an  especially  impor- 
tant result  of  tiie  liath-trealmcnt,  is  scarcely  demonstrai)le  foUowiuj:  the 
tl-e  of  the  antipyretic  drutr-,  with  a  few  e.\ce]>tions.  The  majority,  on 
the  contrary,  in  full  do.-e-  j-ive  rise  to  nuirkedly  depressing  or  directly 
injurious  secondary  eti'ects. 

To  the  sim])le  reiluction  in  temperature,  which  all  these  agents 
usually  liriuLT  aimut  in  marked  dcL'rec,  die  earliei-  siguitican"e  is  hy  no 
means  attached  at  tic  pre-(  ut  day,  a>  has  lieen  seen.  The  custom,  still 
far  loo  common,  of  administering  .inlipyietics  in  a  routine  manner 
wiienevcr  tile  temperature  rcache-  a  certain  level,  .and  thus,  of  course, 
freipieutly,  i-  to  he  condemned.  The  extreme  ell'orts  to  maintain  the 
tcmpcraturi'  :it  a  low  h  vel  for  a  considcnihle  time,  or  constantly 
"  al'clirile."  a-  it  i-  de-iLrnated,  iiv  the  administration  of  salicylic  acid, 
kairin.  tiiallin.  and  tiic  like,  are  actually  dangeroi  •,  and,  tiM'tunately, 
have   licen   almo-t   entirei\    aiiandoned. 

I'ersoually,  I  make  imomparaiilv  t'ar  le~s  use  of  antipyretic  diiigs 
than  of  li.illi-.  I'roni  \ear  to  year  1  have  tri'adnally  given  up  the 
former  inoi-e  an<i  inori'.  and  llic  lar^'c  majoritx-  of  mv  patients  leave  the 
hospital  williont  li.ivinLT  rccci\ed  anv  lA'  tiic-^'  drug-.  I  can  make  this 
>t;itcmenl  vvitli  a  cjcnr  conscience,  a-  mv  c\|iericnce-  durin^j  the  last  ten 
ycar~,   compared    with    tho-c   ihirint:   the   period    in  uhich    I    prescriocd 

'  <''iMi|>;iro  I  111'  ili>.  u-.ion  uiKTi  :ii;'ii|'\  n>'s.  Cmv!.  f  mn.  Mtil..  IHS,',  ;  .ii^il  hitrrnat. 


ruE.infF.yT. 


461 


tlic.-c  rcmidics  more  trwly,  art'  not  any  loss  favorable  tlran  tlic  latter. 
U  at  the  prcM'iit  tiiiic  I  ,-till  occasioiiallv  ailiii'  li^tcr  an  antiiivrctio 
(irnjr,  tliis  is  (Ioik  jircloraiily  in  tlic  so-callcl  liyi.crjiyrotic  ca.-o,  ami 
then  e^iieeiallv  wlieii  the  liatlis  cannot,  lor  extraneou-  or  individual 
reasons,  he  einplov-d.  I  re^triel  niysell',  iiowever,  in  tlii^  eonne<'tioil  to 
a  I'ew  reniedle>,  ot"  niiieli  I  know  tiiat  witii  very  sliiriit  or  no  injiM-iou.s 
seeond-irv  etfeets,  tliev  exert.  In  addition  to  the  rediietion  in  tenijierature, 
also  sdii',.  intluen-e  n|)on  thi'  ty|ihoiil  state. 

I  do  not  use  salii  vile  aeid  or  sodiura  .sahcylate.  Altli<  utrh  they  reduce 
the  hodv-teinperatiire  luarkedly  and  ceriaiidy.  thy  have  neillier  an  alilire- 
viatin^  nor  anv  olher  iavorahle  intlueiii'e  upon  tlie  course  uf  the  disi'a«'. 
They  inav,  in  fact,  not  rarely  he  actually  daii.'en  us,  in  so  far  a.s  ill  y  may 
cause  coliapse  in  |)ersoiis  pr-'.-eiitiuL'  not  entir.ly  n'>rtnal  cardiac  ■oiulitions. 
lutiermanv,  aceon.  ','ly,  the  use  of  the  preparati.  ns  'f  sali  ylie  acid  haa 
appareullv  heen  :•'  .;.ioned  hy  most  physicians:  whih'  in  France,  under  the 
inlluence'of  (Jueimeau  de  Mussy,  Jaccoud,  and  Vnlpian,  these  |ireparations 
are  -liU  employ (>d. 

Kairiu  al.*)  ha.s  proi>erly  lieeii  almost  ahandnned.  Its  administration  is 
likewise  almost  unexceiitionally  followed  hy  marked  de]ire.ssion  of  the  hody- 
teinperature,    hut  irenerally  with   mo-l   uii]ilea,-ant.  often  actrally  alarndii';, 

S( ndarv  manifestations:  cyanosis  with  cold  sweats,  c.irdiac   weakness,  and 

occasionally  [)rof  iriid  disturliance  of  hreathinir.  The  action  of  thallin  apjiears 
to  resemhle  that  of  !:air.:i.  hut  is  attended  with  less  serious  set lary  mani- 
festations. In  the  opinion  of  com|K'leiil  authority,  however,  the  entire  etlect 
is  less  marked  and  loss  persistent. 

I  would  admoiush  also  airainst  the  use  of  aT'lifehrin.  Althoujrh  it  is 
markedly  antipyretic  <  th^-ee  or  four  times  more  so  thai,  antipyrin  s  its  adndu- 
islralion  mav  he  followed  hy  quite  iniantici|iated  and  danperous  seci>ndary 
manifestations,  eyeii  wluii  it  is  triven  oidy  in  stoall  ifises.  1  ndouhtedly, 
even  death  m;iy  he  attrihutahle  to  its  adnninstration.  The  secondary  inaid- 
festalions  in  (piestion  consist  in  chilliness,  cyanosis,  and  csp  •citdly  ir'-eL'U- 
larity  and  feehleness  of  the  action  of  the  heart.  crtam  nld,  r  renudies, 
paiticidarly  veratriu  and  diijitalis.  play  no  rule  whatever  .is  :.ntip_\  retics  "t 
the  prL'sent  day. 

ToLTether  nith  most  i»hysici;ins,'  I  employ  almost  ady  quinin,  anti- 
pvriii,  and  ])hi:tacetin.  < 'ontr:iry  to  :i  niimlier  of  titers,  of  these 
I  .still  prefer  quinin.^  With  a  ]>ro[)er  adininistr:iti' n — this  must 
naturally  he  letirned — it  h;is  :ilinost  as  certain  an  ellVct  :is  the  other 
two,  and  jxeiierallv  a  more  [MTnianeiit  eifect  :  while  such  secotidari-  <lis- 

'  .^oe.  for  initii.  1  ■'.  vcni  Zii'iii-«<'ii.  Hfhrtiuilunr!  i/r.i  Tyi'/ius  ;  I'lTizdclt  u  Suiitzins;, 
Hand    J.    T/,rrnp  ,   l!.l.  i, 

'  See  I,ii4)iTriiii.-ii>r,  '■  Crl.cr  :h'<  .intipyri'tisolii'  AVirkiinir  'li'^  Cliinin."  Pnifxrh. 
Arch.  f.  /Jin.  Mr,l  .  lSt',7.  I'. I.  iii.  ■  .•\nti]1yrl■ti^('he  HoihuctlKKlpn.  '  Zi'm.^.Hnt'n 
Jl'Uiii.  ./.  Tlirrnp.,  lid  i.  ■  fyptius  iilniiimitKilU. "  Ziems^rn' is  Hand.  d.  irprr.  I'afh. 
u.  Tlirrnp.,  liil.  I.  Thp  "  .■Il-kiinwri  invi -ti^ntions  of  I.icliornici^ti'r  nn'  still  at  thi 
prp.^ont  (lay  'Utficicrit  '  ■  ■:'  ution  for  the  Ptnploymont  of  the  fnii'ily.  Kvi  n  ]>rr\  ioiisly, 
Brocii   (1S40)     ill    I     .1  inii   W.   Vc>!:t  il«V.i'»   and  ■\\'ach'^tiinth   flHf,:!)   liiid  made 

invpstipitions  coiu'i'a.,   ,  .j'  itiiti,  without,  howcvpr,  haviiii:  cli'and   up  tlu' situation. 


A 


mi:.-''^^''^'- 


hf 


♦ 


m 


I 


M 


4i;2 


TYfllnlli   ll.Vin. 


tiirliiiicc.-i   as   UKiv  !)r    |iriMiit   ari'    tar  Ic.-.-  <li.-airr.'i'alili:  and  :ilinii>t  frrc 

lii'Mi  (laiiLTtT.       I  lir  i'iii:_'ini:  in   llif  (ar.-.  .-<i  ^li^tl•^■.-^iIlir  to  ntlici'  |ialiriil.-, 

iiiakrs    lillli'    iin|iic.-.-i.'n    ii|"in    tlic  I_\|ilii'i(l    |ialiL'iiI,   mi    arcdiint    ot'    lii.- 

.-late    it'   -liip'.r.       \'(Pinilinir   i-    liv  n<>   mean.-   mi    Ir  iiiirnt    as    il  i-  otlcn 

.siiil  ti>  lir,  aiiil,  what  i-  nlM^t  iniiniriant,  tlio  rrincd^'  i-  llic  Ira.-t  ilanirtf- 

iiiis  <il'  all  ihc-i'  aiili|i\  iTlii    (IriiLi-.  f\  cii  wluii  llic  luart  i-  in  an  nn,-lai)lo 

ciinditiun. 

Tin-  d'l-v  ("T  an  aihill  i>  I'r  in  1  t"  l.."i  j:rains.  llanlv.  I  u'ivi'  as  inacli  as 
-  L'rain.-.  and  .-carci-lv  f\tr  ninrt'.  Ilic  adniinit-lrali'  n  slmnlil  take  iilaiT,  as 
Lii-lifraK'i.-:U-r  rii  i  nnni'nu.-,  not  al  lln-  luiirlil  (if  tlir  t  jnj|ii_Tatnri'-ck'vati()ii, 
but  si»nu'  tiinu  lurliir,  in  •nirr  tn  cdunii  rart  this  s'  1't  as  |ii)s.-iliii'.  As  the 
action  1)1'  i)uiniu  Lriiu'rallv  luM'i.ints  distimlly  a|>|iai\'nt  'n\\\  in  the  ('(jiirsi'  cf 
two  or  thrcf  liour.-.  tin-  <liui'  slii  uid  In-  adininisttTiii  at  Uast  tliis  jieriod  in 
advance  ot'  the  i-.\|n-ctfil  niaxiainni  tiin|i<Taturf.  'I'lu'  dfilino  in  iiodv-titn- 
Iicralurc  Lrc-ncrallv  rcai-hfs  the  h^wisi  hvil.  i>\\  ih  avvra,i.'f.  iVmn  ciglil  to 
twelvf  hniirs  at'u-r  ihe  iiiL'isiii'ii  i.|'  ilic  iiuinin.  It'  tin-  t(  iii]i(rature  tiii'ii 
lu'L'ins  111  ri-i'  aL'ain.  il  dms  iioi.  in  manv  cases,  reach  the  previous  level, 
even  in  the  cnin-, nt'  an  addiiional  iwentv-tniir  honrs.  It  i>nnteu(irthy  that 
the  renieilv  shniild  ln'  aihninistered  at  i'i:ce  in  full  dose,  or  in  ;'.  few  smaller 
doses  at  intervals  ot'  not  loiij.'-cr  than  t'roni  one-<|narler  to  one-half  an  hour, 
Isnialler  <loses  extended  over  a  loiiirer  jieriod  of  time  are  ineHicienI  for  aiiti- 
ji\  retic  ]nir|ioses  -.  l.ieherineister  .  '1  he  rcmeiu  is  hest  adniinistereil  internally 
in  slarch-ca|isiilcs,  t'ollowcl  hv  one  or  two  taliKsiKionfids  of  a  mixture  of 
hvdrochloric  aciii.  Slionld  admiidstrati  ii  li\  the  stomach  he  followed  hy 
voiintinir,   the   remcov    may   readily    \y    ;;iven   hy   enema. 

The  tiiitipyietic  etl'cct  i if  antipyrin  is  inure  nipiil  aii<l  iinire  niaikec! 
Ill  inv  ex|icficiiie,  hdWcver,  it  causes  Vdiiii'ini;  inon>  fre((nently,  and, 
what  is  most  set  ion-,  lieart-weakiu'ss  not  rarely  occni's,  unless  trri'at 
care  i-  oli.-erveil  in  its  adniini.-tration.  I'drst  jirepared  hy  Knorr  and 
introdiieed  into  thcra|iiiitics  hy  Filelmc  it  i>  at  tiie  ]ircseiit  time  jiroha- 
hlv  the  nil  st  coinnioiilv  cin]iloy(<l  anti]iyrcti, .  It  is  hest  a<lministcred, 
as  Id  hertn.  i-tcr  tii>t  snL'L;('~'ed  for  (|iiiiiin,  and  tiien  also  reeoinrneiideil 
for  antijivrin,  diiriiiir  the  af<  hrile  jieriod,  in  order  tlia  its  fleets  may 
he  utili/cd  in  [irevciitiiiLr  the  daily  exae  rhatioii.  Like  iniimii,  it.s  use 
is  f  llowed,  m  t  'iilv  iiv  a  reduction  in  the  hody  tcmiieratwc,  hut  not 
rarelv  al-o  hv  iiniiro\-cini'nt  in  the  no  ntal  stati'  and  hy  ;i  eerttiin  feeliii}^ 
of  wcll-lioini.'.      The  d   sc  i-  iVotn  '1  to  o  (rnim-. 

Wli.'ii  first  aiiminist  reil.  it  is  advisah!.'  not  to  jrive  the  entire  ch  se  at 
once,  hnt  in  tuo  ^  c|u.d  [ar's,  with  an  interval  of  an  In  lir  hetwi  en  them. 
In  patk>nts  in  wliom  tiu  r  ■  is  any  mispiviiirr  as  to  the  ci  nditioii  f  llie  lieart, 
it  is  w  '11  to  administer  ai  fir~t  only  from  1  to  l.o  irrams.  and  thereafter 
hoiirlv  a  ilosc  of  fr.,m  d.To  to  1  L'ram.  The  r'  incily.  if  badly  home  liy 
the  >iomach,  mav  h  administi  n  d  hy  enema,  and.  hy  r<  asoii  of  its  ready 
soliihililv.  (>ven  snhctitancouslv. 


Phenacetin,    wiiich 


dniilar    efVect    to    antijiyrin,    and    is 


eni|.love<l    in    half   the   do.-e,  i.-   advisahle    in    some   eases.      It    is   hetter 


;i^ 


THEMMI.ST. 


463 


l.oriu'  hv  xMiH'  ]);iti(iit^  tliaii  is  aiilii.vriii.  In  its  julmini.-iratiou  also 
till'  cDiiilitiou  (if  the  pill-.-  >linul(l  rrccivf  cari'l'iil  attriitinii. 

With  lactophenin  ((Ihm',  iV.-m  o..")  to   1    crnim),  wiiicti  iias  bwn 

m im.iiil«<l    Ky    \»n   .lakscli,'    iiid    which    ha.-    bmi   credited    liv    this 

chsci-ver  and  also  hy  IiniinTiiiaiiii  with  cxerliii^-  an  specially  t'av..raiile 
inlliicnce  iip'in  the  ^rciural  cciiiditicni  and  with  exhilillinu'  no  serious 
secondary  eH'ccts,  L  iiave  'i-^  ;  "t  not  had  -ntVicimt  cxiiericnee,  hy  reason 
of  the  sli;;ht  nse  that  1  make  of  antiiiyreiic  dnit;-.  Recently,  also 
Kichiioi-st"  has  warmly  |irai.-ed  the  reini'dy  on  account  of  its  action 
upon  the  nervous  sv-tem,  jiartieuiarly  its  sedative  intluenee  upou 
excited,   sleeph'ss    pa:  nuts. 

TREATMENT  OF  THE  DISORDERS  OF  INDIVIDUAL   ORGANS   AND 

SYSTEMS. 

The  treatment  of  the  disorders  of  the  circulatory  organs  has 

alreadv  been  nferreil  to  fn  .pieiuly.  In  this  connection  the  symptoms 
due  to  impairment  of  cardiac  and  of  vasomotor  activity  are  especially 
to  he  taken  into  considt  raii>>n.  How  successfully  these  are  counter- 
acted 1)V  tiie  hath-ircatitient  and  how  'ittle  of  a  favorable  icharacicr 
is,  on  tile  other  hand,  to  he  expected  from  antii)yretic  dru^v,  whii  h, 
on  the  coiitrary,  may  often  he  a  source  of  injury,  has  likewise  I  .en 
snlli^ielltly  empha>izcil, 

Shoiilil  proirres-ive  enrcchlcmeiit  of  the  <-ircnlation  make  ii.-elf 
manifest,  in  spite  of  inteliijrcnily  employed  hathiuj;- tfcatnient,  fiinher 
systematic  intervention  may  he  of  fxreat,  and,  under  some  eircum- 
stances,  of  life-<avin<:,  value.  The  first  place  should  he  taken  hy  the 
employment  of  alcoholics.  Hei;iiinin<j  with  small  (|iiantities  of  mild 
iilcoholic  aijeuts,  the  dose  and  the  -ircni^th  are  gradually  incr.  ..-.-d  in 
propi>rtion  to  the  increase  of  the  collapse.  It  may  in  this  eonneetioll 
he  kept  in  mind  that  febrile  jiaticnts  bear  distinctly  lar<rer  amounts  of 
alcohol  than  those  in  a  state  of  health.  Stroui;  wines,  old  Khine  wine 
or  Jlnr^'undv,  IImif;ariaii  wine,  port  wine,  anil  sherry  are  mostly  used. 
Mulled  win(>  and  champajjjne,  also  eofjnae  in  strotii;:  coireo  or  tea  or  in 
the  form  ot  .'^!okes">  mixture,  are  es|)eciall\-  ellicient.  Patients  who 
swallow  hadlv  or  exhibit  a  di-!astc  for  ah"!  1  may  take  eosrnae,  under 
some  condition-  with  ethereal  tincture  of  valerian,  in  the  form  of  an 
enema  (coirnae,  'JH;  etluTeal  tincture  of  valerian,  ■")  :  yolk  of  efrjr,  1  ; 
mueilaf^e  of  jrum  arabic,  "JO  ;  water,  sufiieitnt  to  niake  lot'  ;  to  be  ^iveu 
in  two  or  three  parts  by  enen-aV 

Amoni;   .-timulatiiiL;  drufrs   I   employ    j^refc  rably  eaffein      nternally 

'  Vrag.   inrd.    II'.cA  ,   is',14,   \,,,   11.  ■  Leiirhuch.  liuw  idition. 


'vm 


^fi^i'm 


vV^'.  "-•- 


'•<■  '^i.   .  -Y*-: 


■■•p-r.;;.  ■-■'S :^;- 


l^^^v^: 


f!?-- 


V*'- 


464 


ivriinni  iivin. 


Mm 


'y  limniiaf 


^filWPf' 


and  suhcutaiRHUisly),  ati<l,  uImivc  all,  fain]iliiir,  wliicli  is  p'lur.illy  must 
ilsdiil.  It-  iiiltriial  almiiii-lralidii,  Imucvrr,  i-  (li-a;rnvaliL  U>  llie 
iKitifiit  ami  i~  u.-clc~s.  I  linM  lore  nniilov  tin-  rciiHilv  a!iiii>,-t  .-nKly 
.sulicutaiicou.-lv.  Tlic  cplliiial  i  !•»  \»v  (■.■nt.  i  caiiiiilMirati<l  cil  i,ra  .-tnui^'iT 
soliiiinii  mav  lir  ii-cd  li.f  tliis  |iur|H.-.'.  'I'lic  tMli'Svini;  sirnnircr  .--olinicii 
is  (•iii])l(iV((l  at  my  dim'':  trimratrd  i'ani|ih(ii-,  'J  ;  sul|iliui-ic  I'tlicr.  .".  ; 
I'llv  nil,  7.'  In  accnrclaiicc  witli  tln'  LTaviiy  ci'  liic  siiuaiioii.  (UH'  or 
twii  livp.MliTiuic  >yriii^nlul-  <it'  this  .~<.ititinti  may  lie  f:ivcii  ivify  Imur 
(ir  two,  anil  •■veil  iiinri'  1rf<|nciitly.  I  iiavf  never  ch-erve.l  .-eri.nis 
secMiKJafV  I  lleets  tVuiu  it-  n-c  I'n  .liajily,  in  snme  case-,  tlie  method 
omtriinites  in  ediisideralilc  measure  to  the  .-neeessl'id  (inteoine.  Of  the 
stiheiitaiUMiii--  a<lniiiiistratinn  of  pure  etiier  I  rarely  make  any  use.  Its 
eil'eet  is  di-tinetiv  le>-.  .-ertaiu  atid  ].er,-i-tent  than  tiiat  of  eaii.|iiior. 
In  adiition,  the  injeetions  are  cinite  paiidul,  and  not  rarely  ^dve  ri-<'  to 
iieeror-is  at  till  point  of  piinetiire.  Mii>k  has  larj^ely  ;;one  (;ut  ot  use, 
an<l  it  r.i.pear-  to  me  that  not  niiieii  lias  been  lo-t  in  eon-e(|ilonee. 

At  time,-,  espeeialiy  in  l,y [ii  rpyretie  ease-,  an  iee-liau-  applied  over 
the  heart  remlers  ._rood  -er\  iee.  In  a  numher  of  Ideily  or  olher\vi>e 
decrepit  individual-,  warmth  to  the  preeordium,  |ireferahly  applieil  hy 
mean-  ot'  I.eiter's  tiilie-,  may  lie  of  -erviee.  Should  tiie  extremities 
lieeoine  eojd,  the  a|. plication  of  handap-  and    hot   l.ottle-  -hould    not  he 

Iletrleeted. 

Digestive  Orgaus. — Tlie  care  of  the  mouth  and  the  na-opliar- 
VHL'eal  eavitv  lias  already  t"in  coii-idered.  .\  inimher  of  infeetioii.s 
di-ordci-s  of  the  larvnx,  tlie  iiroiiehi,  and  the  Iuiil's  may  in  this  way  he 
aveni.l.  Tiiat  artitlcial  teeth  -lionld  lie  ri'iuovod  throuirhout  the  entire 
febrile  period,  e-peeially  in  the  ease  of  deeply  slu|.orous  jiatidits,  is  a 
matter  of  eour-e.  The  developnient  of  thrush  should  be  attacked 
vii^oroii^lv  on  its  lirst  appearance.      In   the  ])resenee  of  jiarotiti-,  which 

f|-.<|Ucutlv  Mili-ide-  without  the  oeelirrenee  ol'  -llp])Urati(.n.  cold  elolh.S 
or  an  lee-baL'  mav  be  aiijilieil.  Should  suppuration  prove  inevitai)le, 
hot    poultice-    -hould    be   applied,   and    then    free    inei-ions   be   made   as 

carlv  a.s  jios.-ible. 

The  intestinal  symptoms  are  L'en<rally  a  ,-ouree  of  e-peeial  anxiety. 
For  the  diarrhea,  which  trctierally  is  not  attended  with  marked  fre- 
cpienev  of  bowi  l-niovemeiit  in  cases  of  tyjilioid  fever,  intervention 
should  be  undertaken  oidy  if  the  stools  are  unusually  nunierous  and 
attend(>d  with  peri-ta!ti<'  unrest,  eoKhky  pain,  and  tenesmus — the  last 
oceiirriu'_'  more  commonly  in  e.ises  of  c,,loiyphoid.      In  -onie  ea-es  it  is 

'  Til.-  :i<iilili-ii  <.f  til"  itliiT  i-  im.n.lc-a  only  fnr  !)!.■  pviqi..?"  ,,f  Miakinu'  ll..'  luixture 
more  liiii]iid.  and  therefore  morr  nvaiUble  for  injecti  n. 


Ti!i:.\T'fi:\r. 


465 


then  ailvisal)lc'  to  wiililiiil<l  milk  ami  ifTfr^  and  to  administer  only  small 
quantities  of  miicilairinniis  snups  or  cocoa,  and,  in  aildition,  under  cer- 
tain eircinnr-tanccs,  soini  ](ort  or  red  wine.  As  a  JMverage,  weak  cold 
tea  is  mueli  to  be  jin  t'crred  to  tiie  ;jum-\vater  or  alliumin-watur  custom- 
aril)  employed.  An  iee-liaj;  upon  tlie  alidonien,  ot'teii  liiirliiy  praistnl 
in  thi.H  connection,  is  ranly  well  linrne.  Tepid  allusion  is  liest.  Poul- 
tices may  be  pcnuitted  only  under  special  i!  liditiois.s,  as  tlicy  increase 
the  danijer  of"  the  occurrence  of  intestinal  lieniorrlia};e. 

Of  drugs,  if  dietetic  measures  do  not  sutlice,  I  employ  opium  almost 
S<dely,  giving  it  in  freipieiit  small  dose.-,  ir-  part  by  tlie  mouth,  in  part 
in  the  form  of  suppositories,  employing  the  latter  particularly  when  it 
is  thought  that  the  colon  and  the  cecinn  are  especially  involved.  Little 
aid  is  to  be  e.vpected  from  astringents.  Conversely,  persistent  consti- 
pation, which  is  bv  no  means  uncommon,  may  rcijuirc  intervention. 
C'ontrarv  to  the  eusioni  of  a  numbei'  of  other  elini<'ians  who  are  less 
strict,  1  never  employ  laxatives  under  such  cireumstani'cs — not  even 
castor  oil  or  calomel,  which  are  in  great  favor.  Simple  enemata  of 
water  sutlice,  as  a   rule. 

Marke<l  tneteorism  in  patients  wliose  dietary  has  not  Im'  npglccte<l 
is  almost  alway-  tlie  exjire-sion  of  profoinid  intoxication.  I'nder  such 
Conditions  te])id,  gradually  coole<l  full  baths  are  especially  indicated, 
an<l  iu  the  intervals  nioi^t  alVu>ions  or  aa  ice-bag  -hould  be  applieti  to 
the  ..bdoiiien.  Should  tiiese  iiiea-ures  afford  no  relief,  not  much  de])end- 
ence  eaii  be  placed  upon  others.  I  have  observed  scarcelv  anv  giKnl 
from  the  use  of  oil  ol'  uirpentinc,  externally  or  internaliv.  in  s|)itc  of  its 
fre(pient  reconuiieiidation  by  early  ])raetitioners.  The  lii<rhlv  praised 
high  introdiiet'on  of  a  rci'tal  tube  also  will  be  succc.-  :'ul  in  onlv  a 
minority  of  casis.  At  oest,  I  have  l)oeii  able  to  evacuate  gas  through 
it  only  vviien  the  nieteorism  wa>  confined  ])riiicipallv  to  tlie  large  intes- 
tine. When  especially  the  small  intesti.ie  is  greatly  distcndtnl,  not  much 
will  be  accomplisheil  with  the  tube.  Direct  puncture  of  the  intestine 
with  a  fine  needle,  v.hich  has  received  nvonmiendation  from  various 
sources,  is  dangerous  on  account  of  the  li;d)iliiv  of  peritonitis.  At  any 
rite,  by  reason  of  the  marked  jiarcsis  of  the  intestinal  tulK",  almost 
always  jiresent,  and  the  con-idenibl(>  loss  of  elisticitv  in  the  overdis- 
tcndeil  :il>domlnal  wall,  no  gas  will  escjipe  thniugh  the  neeille,  for  . 
obvious  ]>hysieal  reasons. 

In  the  ])re,-ence  of  intestinal  hemorrhage,  and  even  nivm  the 
slightest  indication  thereof,  absolute  rest  in  the  dorsid  <lecubitiis  is  neces- 
sary, and  the  abdomen  should  be  coven^l  with  an  ice-bag  or  a  coil  of 
cold  water.     The  patient  should  for  a  ti..ic  refrain  from  the  ingestion  of 

3U 


mi:!^?mi^^^^^^Lmmmiiiwm 


^1 


lifi 


4t;t) 


ryriiDin  n:vi:n. 


all  tiMiti.  At  most,  Kit-  "('  ice  or  cold  ten  in  >|>«Minriil  (1iim'.>  may  l)c  ^ivcii. 
Il'  tlic  luniiinliiiL'"'  i^  liirlit,  nr  on  the  cositioii  <>['  more  copious  litiiKir- 
rlia^'r.  a  -pnoiilul  of  imiM  milk,  or  a  corn-iioiMliiii:  amount  of  niiiciiaf:!- 
iioii-  sou|>.  mav  !«•  i,'iv(ii  cvirv  two  or  tlircc  lioiir^.  Control  <if  iiitos- 
tiiKil  i>»ristal-is  >lioiil(l  i>c  proviiitd  for  l>y  means  of  o|iiiim,  in  fri'(HH'nt, 
c'vtii  litroic,  llos(•^.  l(v  til"'  nioiilli  or  tlic  nciiim.  In  llic  jirt'stncc  of 
frcnt'i-al  restl('ssn<  S7-,  one  slionitl  not  lioitatc  to  a<lmini^ltr  a  suhoma- 
lUMius  injection  of  morpiiin. 

Tlic  druj:^  rccommcrticd  as  dinci  hemostatics  arc  less  trnstworthy. 
Sime  emplov,  witli  i:i"'il  rcsnll.-.  it  is  stated,  snlxlernial  injections  of 
c-iroliu.  N'otliinjx  is  to  !)<■  cN]iectcd  from  internal  styptics  or  astrin- 
gent-, es]H'ciallv  the  niiich-recommendiKl  solution  of  ferric  chhjrid. 
Thev  mav,  on  the  contrary,  he  directly  d  infreroiis,  from  the  fact  that  at 
times  thev  excite  vomitinj.'.  Mhcn  the  jialients  hecome  fcchlcr,  it  is 
wi>e  not  to  resort  to  the  use  of  stron;:  stimulants  too  early.  Moderate 
collap^^e,  if  iiitelli<.n  ntly  controlled,  may  he  fav  irahle  to  tlironihosis  of 
the  hletHJinp  v<'sscl.  In  the  pre-eiice  of  considerahle  cardiac  weakness 
following;  protu-^e  hcniorrha>:e,  these  considerations  may  naturally  \.i 
iimori-*!.  I'tider  such  circumstances  the  treatment  already  described 
for  eollai)se  will  he  indicate.!.  In  some  esiieciaily  alarminfr  cases  I  have 
ol)serv(Hl  piod  results  follow  the  suhentaneous  ■  intravenous  infusion 
of  wniium  <'hlorid,  and  even  from  transfusion  of  hlooil. 

The  u-c  of  c:dcium  chlorid  in  iar>:e  doM-  (•_'  frra-u-  every  three  or 
four  hours),  and  tiie  suhcMtaneous  injection  of  a  2  ])er  cent,  solution  of 
irehitin  in  order  to  incrca-e  tlu'  <M>a^'nlaliility  of  tlie  hliK.d  and  so  favor 
thronilHi-is  in  the  hlecdin^r  xe-sel,  liave  liecn  lately  tried  at  the  Johns 
Hopkins  no>i)ital.  in  -omt>  ca-es  apparently  with  <roo<i  result,-. 

Intestinal  Perforation.  —  Kecently,  surpery  ha.s  undertaken 
intervention   in   the^'  rase<,  residtinp  in  the  saving  of  life.      The  fir.st 

attempts,  in  the  pres.nr f  perforative  peritonitis  complicating  typhoid 

fever,  to  <»i>eii  the  ahdominal  cavity,  to  search  for  the  site  of  perforation 
dire<>tlv,  and  to  dose  it,  and  thin  t  ,  make  a  thorough  toilet  of  the 
peritoneum,  are  due  to  Mikuli.v,'  and  J.ii<ke.-  They  have  l)e<n  followed 
i)v  a  large  nund.er  of  surgeons,  some  of  whom,  especially  courageous, 
liave  even  earnestly  recommended  resection  of  the  [HTforated  portion  of 
the  intestine. 


>   y,.lkmnnn'.t  SnmmliiJirj  Uin.    V'rtraar.  No    '.'R'-V 

'  Pculxrh^  Text.  J.   Chvr..  Is^ST.   Hd    xjv,:   and   V.rhandl.   ,\.  dndsrhrn  GFS^flUrhnft 

n„r..  1880       A  complete  MMioixraphy  Lciriiii:    upon   tlio  j.n n-durc  in  .|unsii..r  is 

vpn   l>v  r.psr-lpwitz.'^.h  and  W,inna.k.  MMhed.  au.i,Un  Grcmgf  bitten  d.  M'd.u.  Chir., 


Bd.  ii.,  H.  1  u    -2.  S.  .TJ.  rl  .if/ 


Ti:i:.[rMi:.\r. 


467 


Tlic  ilotiiil-  ;iii<l  iriitliM<l~  of  ii|)<'nitiiij:  iimrr  ifniitly  ciiiiiloyrcl  ;ire 
lullv  cim-idiivd   in    tlic  uiiliii;;-   ol'  llic   -ur^ is   nlirrcd    I'l   "ii    pii^'i-s 

Ill  V  u  w  >>(■  l!if  lAciH.iit  it-iilt-.  ohlaiih'il  liy  llu'  ii-.' <il' tlii-  iirocoliiru 
(liiriii<;  tlic  |>a-t  r<\\  \>:ii-~,  ami  -incc  llic  cliaini-  i\<v  -ikco-  Iiumi  ii|>(i-,i- 
tiiMi  arc  tar  u'lcalrr  tlic  carlitT  it  i^  iiiidcitakcn,  it  i-  of  the  iitino-t 
iiiiiiniiaiKi'  tiiiit  lli«'  n.iiil:  '.ill  lie  niof^iii/cil  caily  ;  and  wiiii  iiirn-aMS 
ot"  skill  ill  carlv  diajrim-i^  will  li.uhtiMlly  come  an  a|i|iri'(ial>li'  reduc- 
tion ill  the  iiiMi-Ialitv  frniii  thi^  accident.  The  alteiidiii^^  |iliy.-iciuil 
sinmld  liavc  tlie  |n(— iUility  of  |iertoi-atiiiii  constantly  in  mind,  and  with 
the  onset  of  the  tir-t  -ii-i)i<'ioii^  -ym|)toms  a  nio-l  careful  examination 
should  be  made.  All  feeding,'  should  lie  .-lo|i|.ed  at  once,  all  forms  of 
liiith-trt-.itment  should  lie  diseonlinueil,  alisolule  n -t  ^hould  Ik>  niaiii- 
taiiii'd.  and  the  patient  shuiihl  Ix  watch  d  with  the  jricalest  can>  until 
all  iHi-sihilitv  of  till'  exi-tence  of  a  perf n-atioii  has  passcil.  (in  rejrard 
to  eailv  diajiiio^i-,  ~ee  p.  '2-'>\)  'I'lie  u>e  of  opium  in  these  ca-es  is 
ju-tifial)le  onlv  after  the  diai^iio-is  has  heeii  made  and  operation  d( cided 

iiiioii.      As  soon  a'-  perforation  is  helieveil   to   lia\( urrcd,  immediate 

surgical  intervention  is  demanded.  The  results  of  this  procedure 
(p.  '2:]'i)  fiillv  warrant  it-  application  wherever  conditions  are  such  a-  to 
render  laparotomv  for  aiiv  other  conditii>n  Jii-tilialile.  'llie  introduc- 
tion of  the  use  of  local  cocaiii-anesthe-ia  in  thei'  cases  liy  ('usliinji  has 
Imh'II  a  di-tinct  advance,  in  that  it  has  maile  the  operation  [Missihle  in 
manv  (;ases  in  which  the  administration  of  a  jrencral  anestlieti<'  would 
ot'  iiself  lie  a  source  of  coii~idcral)le  danL'<'r- 

Kven  in  cases  in  which  the  pertiiratioii  has  not  lieen  re<oirni/<'d  early 
and  ijenenil  peritonitis  is  present,  hope  mu~t  not  lie  lo-t.  No  <'ase  is  so 
desperate,  unless  actually  morihiiiid,  as  to  he  without  snme  ho])e  in  the 
1  Mids  of  a  ijoihI  siirf^eon. 

Cholecystitis. —  I'he  tpiestion  of  siir^dcai  treatment  has  Ix'en  eoii- 
>idere<l  hv  the  authors  ipioted  on  jiajjes  •Jtlit,  2\'K  I'lidouhtedly.  many 
of  these  ca>es  recover  without  such  intert'erencc.  However,  this  is  not 
true  of  a  majority  'A'  the  cases.  Of  II  cases  of  typhoidal  infection  of 
the  jja I l-l (ladder  aeeoiii|(anyin'.r  or  following'-  ty|thoid  fever,  collected  l>y 
Keen,'  .">()  resulte<l  in  perforation.  Of  these  ."iO  eases,  4  were  o|)enit«^l 
n|Miii,  and  of  these,  .'>  recovered;  while  of  the  reniainin);  i*)  not  ojvr!it»>d 
iij)on,  al!  dieil.  There  ("an  therefiire  U-  little  (juestion  as  to  the  advisa- 
liililv  of  operation  as  xMin  as  perforation  is  diaf^nose*].  .Vs  to  op'ration, 
in  cases  ot'  cholecystitis  with  marked  distention,  Itefore  perforation,  the 
opinion  of  Keen-  may  l)e  (pioted  :  "  I  am  decidedly  of  the  opinion  that 
'  /,.«•   cit.  '  (  iinmc    ,/ ./ffi.i  Iliipkins  Ho.ip.  Hep.,  vol.  viii. 


[ 


u 


■\r,H 


TYfll'ill'  t  ivi.n 


p.  Iiii:^' 


'^-■ 


in  .li-t.tili..li  .it' ill.    -ill-lil:i.|.l.r  l.r..ini.l  Mir-i.Ml   int.  rt'.ivn.r  i-  tin-  l«'-t. 
It    i-  WiV    Intlrr    1..    |nv\.iit    |»rl'..r:iti..ii    tlwiii    l.>   r.iii.'tK    it  aft.  r    it    lias 

iic.iirr.'.l. 

<  »|.(  niti..ii  ill  Ml.-.'  .a-.-,  al-..  uimI.  r  l."'al  .■...aiii-aii.-tli.-ia,  lia-  I.-ni 

iJMii.-  !i\   <  'ii-liiiiiT  ami  l.\    Mii.li.  H. 

Siij.].iirativ.'  .■Ii..l..v-tili-   an.l    .li..!.  litliiaM-    •..ll..u  in-  l\  |''"''''    '''■^"' 
f;li.iiil(i,  ..I'  .■..nr--r,  ri-.fi\.'  -uriii'-al  1  r.  atintnt. 

Iho  diseases  of  the  respiratory  organs  may  n-piiiv  tli.n- 

pcuti.'  intcrvcnli.in.  Marlv.!  .l.-iv-  ..f  li..-.-t.l.<Ml  aiv  w.rtliv  ..f  all.ii- 
ti.in   <.n   a<coiint   ..f  tli.'  alr.a.iv  iv.liic.l  (■..n.liii..n    .il'  tli.'   ptilitiit    iV.un 

,,tliiT  -Miisf-.      A    niiiiilicr   ..I'  .l.atli>    have    n  suited    IV tli.'    .iiviini- 

staii.f  that  til.'  patioiit-,  stiliH,r..ii.  ..r  sL-imm^:  ]ir..tniiii.ll\ ,  . -i...  ially  if 
til.'   nasal  orilicf   lias  Ih.mi    taiiii".ii.il.  Iiav.'  l..sl    an  iniiiuiiM'  am. .mil  .'f 

1,1 1  int..  th.'   na-..|.liaryiiui>al  .'av  ilv  an.l    liav   -wall'.u.'.l  it,  in.'..n-.- 

.lu.tirc  ..f  wlii<-li  iIm'  li.'m..nliair.'  'Ii..'s  n..t  i.n.iiiptly  .  ^^v  t..  th.'  kii..ul- 
clir,.  .,f  til.'  atl.ii.lanl--.  I  liav.'  ma.l.'  it  ;i  nil.'  in  -.•vciv.  ..l.-linate 
ca-i's  ..f  f|)i-la\i-  t"  applv  tamiM.ii-  ii..t  al..n.'  iV.nii  tin'  fnnit,  l.ul  al-o 
fiMiii  iii'iiin.l. 

Tlic  tivatm.'iit  .if  tlic  l\iili..i.l  l.-i..ii-  "f  lli''  lar\n\  lia-  aliva.ly 
■rivfii  rise  t.i  an  .'Ni.'iwivi'  lll.a-atmv.'  Ii  tival.-  .-ixrially  ..f  lli''  in'li- 
.•ati.,ns  f..faii.l  tli-  [HTli.rinan.  .•  ..f  Ira. li. ..I. .my,  witli  \\lii.-!i,  in  -cvire 
ca-cs.  tli.T.'  -li..ul.l  !»•  ti...l.la\.  'I'll.- ..|..Tati..ii,  Im.wcv.t,  ha-  aU"  its 
(lark  si.h',  .-ii.'.'ially  in  <-as.s  ..f  ty|.h..i.l  f.-v.T,  inaMim.'h  a-  in  tlu-iii, 
fi-  m.ir.i  than  in  ih..-.'  I'lv  fn.m  f.  \.  r.  it  fa\..rs  ih.'  ,l.-vc!..pmciit  .if 
pn.iim.iiiia,  Imth    hy   a-|iiiati..n    an.l    l.y    r.M.'iiti.iii   ..f  s.'cr.ti.m. 

On,,  nni.-t  ahvay-  h.  ]iiv|ian'.l  f.-r  ih-'  .l.'vi.l..iim.'iit  ..f  ali-<'c:-s  ..f  the 
thvn.i.l  trlan.l,  "M  ac.,,imt  ..f  it-  irravity,  l.iit.  ('..rtmiauly,  it  i-  ii"t  fn- 
,|iiCnt.  It  S...1I1  L'iv.-  ri-..  t..  attack-  .if  snn'.icati..n,  ami  it  sh.ml.l 
thiT.'f.irc   he   iiii'i-f'l   as   early  as    jxi— ihlc, 

Mv  far  the  hc-t  treatniciii  i'lr  typlinid  linmchitis  i-  that  with  bath~, 
cohl  fri.'tion.  an.l  nmi-t  a|>|.li.aii.iii>.  I  scanvly  c^.t  iis.^  the  so-caUe-l 
i.xjurt.iranis— iixM^acuaiiha.  HiicL'a.  .I.'.  WIk'Ii  imi".rtan.c  is  attached 
ti,  tlu,"  use  ..f  drill's,  tlu'  ailmini-trali..n  .«f  li.|.  anini.m.  ani-.  is  least 
iniuriDUs.  Sh.iul.l  ^ymi.t.ims  ..f  .•ardiac  vvakness  U-  a.ld.-.l  t..  lluise  ..f 
lin.n.'hitis,  measures  ,liret..l  e-|iecially  t.>  the  jirovcnti.m  .-f  imlin.mary 
hy|..istasis  are  in.li.atc.l.  Tnder  such  circuni-taiices  fre.iuent  chancre 
.if  jv.Mti.m  sh.iuh!  he  hr(iu._'ht  alx.ut,  and  an  endeavor  sh..ul<l  he  made 
t.i  inipriive  the  eiifeehle.l  .anlia.-  a.tivity.  In  s.mie  .'a-es  the  apiilica- 
tidii  .if  drv  cups  .ivcr  the  rc^'i.m  .if  the  l.iwer  Idies  ren.ler-  L'n.,.1  service. 

>  S...   Ihp  r..f..n.:u-s  <.n  (.«-.•  l-':!''  im.l    tl..-  fMllowi..;;   \nvz<-*  -f  H'i-  wrl<.  (-l..ri>illy 
tlip  exhaustive  work  uf  Luniiij:  iIilt.-  iju'iithhi'd  ^i.  i;4;!;. 


^:f<cif'. 


.^i^fv;''"V»-    -»^*^,,>rsv«     ,f^/ 


•3i:i 


inilMMI-.W 


Jtjy 


The  trcatmtMit  of  disorders  of  the  nervous  system  i-,  as  has 
ulri'iiilv  Ix'cn  |Miii)t(<l  (lilt,  likewise  one  of  llic  |iriii<i|>;il  use-  of  liydrt)- 
tlicrapy.  A  muiiiIxt  <<{'  .IriiL'^  :il-"  (i|Miiiiii,  aiilipyriii,  plicnacftin,  and 
lactoplifiiiii)  appear  to  r<nil<>r  valiiaMf  -irvui'  in  tlii:-  connwtioii.  In 
atldition  to  the  i^'cticral  aiitipyr  tie  tnatmciit,  >p.ci:il  nnasMrf>  and  modi- 
fication:* of  liydrotlu'ni|M'ntic   inftlio<ls  may  Ix' ic   n«'<cssary.     S-vere 

licadaclic  durinsj  the  first  pTUKl  of  the  discasf  should  lio  rdicvc<l  l)y 
m(!:ins  of  the  ice-liac,  l-eiter's  iroils,  or  hy  plaeinn  the  liead  iiixui  water- 
<'iishioiis  kept  lonstantly  eix)!.  Under  siieh  eireinnstanee-s  a  do.-e  of 
antipvrin  or  phenueetin   also  otl^-n  yiehls   the  U'st    results. 

At  a  later  p<riod  of  the  dise.ise  the  sensitive  sUites  of  the  nervous 
system  and  the  depressive  states — eoina,  soinir,  stup>r  with  eataleptie 
symptoms — often  recjuire  sjn-oial  trciitment.  The  depressive  conditions, 
when  they  atUiin  a  eonsiderahle  de^rret;  of  severity,  should  he  controlleil 
hy  means  of  cold  douches  in  the  tepid  hath,  and,  in  particularly  rohust 
persons  and  when  the  attiick  pursues  a  iiyperpyretic  course,  even  hy  means 
of  (piite  cold  full  l)ath-.  A  useful  adjunct  under  such  conditions  con- 
sists at  tim»'s  in  the  cnemata  of  valerian  and  eojriiac  previously  men- 
tioned. In  the  presence  of  niarki^l  irritative  states —<lelirium,  attempts 
at  tli^ht,  and  sleeplessness — iirotr.icted,  simple  tepid  or  jrr.idually  cooled 
von  Ziemssen  haths  are  indicated,  ("old  douches  ami  similar  measures 
rarelv  do  tr""«l  under  such  cinum-tances.  (Jreatly  dehilitate*!  indi- 
viiluals  inav  he  treated  advantajreously  with  tepid  wet-pai'ks  in  place 
of  the  l)aths,  hut  in  order  to  secure  the  necessary  rest  for  the  patient 
the  packs  should  he  chauircd  infrciiuciiily.  If  restlessness  he  par- 
ticularly marked,  one  should  not  hesitate  to  irive  tnixlerate  doses  of 
piorphin  ;  thev  never  do  harm,  and  tiiey  help  to  ppotect  the  hrain  from 
exhaustion.  In  drinikards,  alcohol  should  he  pven  frcnerously,  in 
addition  to  m,  ; ;  liin. 

(){  the  organs  of  special  sense,  the  car  particularly  shotdd  he 
ijiven  consideration.  In  profoundly  stu]»oroiis  patients  fre(pient  exami- 
nation is  necessarv,  even  thoufxh  they  make  no  complaint.  Should 
inflammation  of  the  middle  ear  develop,  the  e;irly  |H'rformance  of  para- 
centesis of  the  tympanic  memhrane  is  recommen<led  hy  most  aurists. 

External  Integument. — With  the  present  system  of  nursinjj, 
the  occurrence  of  hed-sores,  even  in  severe,  protracted  eases,  is  excep- 
tional. Profoundly  ill  patients  should,  from  the  l)ojrinninj;  of  the  s^'cond 
week,  he  ])laced  upon  a  water-hiil,  as  von  Ziemssen  and  Immermann  first 
rceommendcHl.  If  this  he  comhined  with  the  strictest  cleanliness  and 
appropriate  bath-treatment,  h(><l-sores  can  almost  certaitdy  \w  avoidixl. 
Placing  the  patient  upon  air-cushions  likewise  is  usually  sufficient. 


^^.•• 


V*:.  , 


-"Iftl  ■■ 


.»•     ' 


'-^h- 


MICROCOPY    RESOIUTION    TEST    CHART 

ANSI  ond  ISO  TEST  CHART  No    7 


1.0 


I.I 


m  iiiiiM 

i:3  6 


t  ,    Ii6     lllll  2.2 
t. 

III!  2.0 


li 


1.8 


1.25 


1.4 


1.6 


A     /IPPLIED  IIVVIGE     Inc 


•^oiiMestc.    N?"    ''^"»  '"buy 

.  716)   *82  -  0300  -  Phone 
(7t6)   288  -  5989  -  Fo» 


470 


TV  nil  HI)  iE\i:n. 


M^ 


Air-cushions  anil  water-cushions  sliouhi  always  he  covered  wiih  a  s^heet 
free  from  folds  and  of  not  too  coarse  texture.  They  siiouhl  never  l)e  unduly 
filled — in  i:eiieral.  only  to  such  a  dejrree  as  not  to  rise  above  the  level  of  the 
remainder  of  the  bed  when  the  patient  lies  upon  them.  I  have  water-cush- 
ions tilled  only  with  tepid  water;  the  use  of  cold  water  is  uimecessarv  and 
disairreeahle  to   most  ])alient3. 

If  a  typhoid  jiaticiit  proent.s  a  hf(l-H>rc  when  he  conies  under 
observation,  or  if  such  a  condition  catmot  be  [ircxcntcd,  in  stiite  of  the 
utmost  ciiro,  it  should  be  treated  in  accordance  with  the  rules  of  anti- 
sepsis. Tiie  application  of  plasters,  formerly  practi.scd,  is  to  be  rejected, 
on  acciiunt  of  the  dani,'er  of  retention  of  the  .secretions  of  tlic  wound. 
Dressinfjs  with  borated  or  other  antiseptic  ointments  arc  most  suitable. 
The  fortunately  extremely  rare  ca.se.s  of  very  extensive,  multiple,  and 
progressive  h-d-soros,  attended  with  general  nutritional  disturbances, 
can  at  times  be  favorably  influenced  by  treatment  in  a  permanent 
water-hath. 

The  treatment  of  erysipelas,  furuncles,  and  phlegmons  should  be 
oarriiKl  out  in  accordance  with  general   rules. 

With  reference  to  typhoid  affections  of  the  kidneys,  it  need 
oidy  be  remarked  that  they  do  not  contmindicate  mild  bath-treatment, 
while  under  such  circumstances  certain  antipyretic  <lriigs,  particularly 
salicylates,  arc  strictly  to  be  avoided.  That  the  bladder  should  be 
freijuently  examined  in  the  case  of  profoundly  stuporous  tvphoid 
patients,  and  if  necessary  catlieteri/ctl,  cannot  be  too  dceplv  impressed 
ujH)n  tlie  young  |)liysician.  When  bacilli  are  present  in  the  urine,  as 
demonstrated  by  cultures  or  shown  by  the  microscope,  unitropin  should 
be  given  in  in-grain  do<es. 

With  reg-ard  to  the  tnatment  of  especial  varieties  of  typhoid 
fever  some  stat.'inents  have  already  Ikhii  made.  The  hvpcrpyretic 
variety  reipiircs  e-pccially  keeping  the  patient  in  a  cool  stiite.  frc(|Uent 
cool  baths,  and  not  nirdy  antipyri  tics,  aitioiig  which  I  prefer  (luinin. 
In  the  varieties  attended  with  septic  manifestations  I  have  at  times 
obsei^cd  good  result-  from  the  usc  of  fni|ueiit,  fairlv  large  do.ses  of 
antipyrin.  The  so-called  hemorrhagic  variety  has  as  vet  proved  little 
amenable  to  treatment.  The  use  ot"  calcium  chl<prid  and  the  subcutane- 
ous injection  of  gelatin  solution  shouhi  be  iriiKl.  The  highlv  lauded 
employment  of  ergot  aixi  the  acids  is  worthy  of  little  confidence.  The 
conditions  present  c(  nsist  in  profound  disturbances,  which,  .so  long  a,s 
they  are  not  understood  etiologically,  are  not  accessible  thcrapcuticallv. 
That  mixed  forms  of  typhoid  ii^ver  and  malaria  demand  ener<retic  treat- 
ment with  i|uiuiu  iieeti  scarcely  be  sjwcially  emphasized. 


4  .3 


tiu:atmi:st. 


471 


TREATMENT  OF  RECRUDESCENCES  AND  RELAPSES. 

We  liMVc  alr.ady  learned  to  apiueeiale  tl;e  >erinu>  pnifrnosis  of  true 
reerude-eeiiee.-.  Tlieir  treatment  U  ttie  same  as  tliac  iif  tlie  severe 
tvpliiiid  statt'  in  L^enei-al,  witli  especial  ei>n>ide-atioii  for  the  eireum- 
i-tanee  tliat  tlie  patient.-,  already  ^neatly  redne(  d  in  eonse<|iienee  of  tiio 
antecedent  period  of  disease,  are  pre<ii>posed  to  cardiac  weakness,  piil- 
tnonarv  liv|(ostasi>,  and  -tates  ot  profound  nervou>  cxiiaustion.  Only 
the  milde-t  liv<lrotliera|ieutic  measnns  ci.n  i)e  employe*!.  Cold  full 
haths,  doucli<>>,  and  the  like  are  entirely  to  he  avoided.  The  most 
important  eon>i(leration  under  these  cireunistances  is  suitahle  nourish- 
ment and  ahundant  administnition  of  stimulants,  especially  alcohol. 
The  relapses,  which,  on  the  contrary,  are  of  favorai)le  pro(rii.i-i-,  reipiire 
treatment  oiilv  when  they  are  ahnormally  ])rotraeted  or  when  a  severe, 
lonji-enntimied  relapse,  following:  :i  mild,  at  times  amliulatory,  primary 
attack,  con-tilnte-.  actually  the  |.rincipal  part  of  the  entire  disease'. 
I'lider  such  circumstances,  naturally,  the  lules  already  laid  do,vn  for 
the   |)riniary  attack  are  applie;il>le. 

Whether  relajjses  can  he  prevented  when  their  imminence  is  to  he 
fearinl  on  account  of  the  persistence  of  enlarirement  of  the  spleen  and 
of  the  diazo-reaction  into  the  afebrile  jycriod,  as  well  as  the  relation 
hetween  the  ])ulse  and  the  tem](erature  p?-eviously  mentioned,  is  douhte<l 
by  many.  I  believe  with  von  Ziemssen  that  this  is  jMissible  at  times 
by  ajipropriat*'  treatment  with  (piinin.  I'nder  such  circumstances  I  do 
not,  however,  administer  sinjrle  larirc  i1<.ms,  Im'  smaller — from  Orl')  to 
0..")  jrram — four  times  daily,  and  occasionally  even  more  fre(inently. 
The  same  treatment  has  been  serviceable  also  in  eases  in  which,  with  or 
without  persistence  of  eidar^ement  of  the  spleen,  the  temperature-curve 
acipiircs  a  wholly  irreirnlar  character,  and  with  normal  or  subnormal 
dailv  tem|K'rature  exhibits  moderate  elevation  toward  eveniiifr.  I 
believe  that  I  have,  hy  meaTis  of  treatment  with  <|uiuin,  materially 
shortened  the  duration  of  a  number  of  such  cases,  which  experience 
had  shown    rnii.d't   be   |irolonjred   indctinitily. 


TREATMENT  OF  CONVALESCENCE. 

\  principal  point  in  the  treatment  nf  couvaleseence,  attention  to  the 
nutrition,  has  alnadv  been  ret'erred  to  (p.  451).  Not  less  closely 
than  this  should  als.i  the  L:<ticr;d  physical  and  mental  condition 
of  the  |)atient  be  watched.  lie  should  not  be  permitted  to  irct  out  of 
bed  too  soon  ;  and  it  is  welt,  both  for  the  patii'iit  and  for  the  friends, 
f-.oiu    the  outset    to   name   the   nnich-lonp-d-for  dav  rather   t<io    far   in 


i'f 


f  I' 


472 


TV  I'll' I  ID  IKVF.n 


''HnttI 


^il 


|i 


mlvaiicc.  F*'viii  ;if't<r  iiiilil  attnk-  <'o!iviilc.-((iil>  -lioiild  not  he  [mt- 
iiiilt<il  (o  mt  iiiu  oT  lied  carlid  tliail  two  week-;  alter  (ictiiiitc  doti-r- 
VfscciKc.  After  -eveie  attaeks  tills  pial  will  >careel\  lie  reaelied  iM't'orc 
the  la|»e  ot"  four  week-.  C'omi)lifatioiis  ot'teii  re(|iiire  roi  in  lied  lor 
even  iniieli  loiii.'er  periods.  The  patient  and  the  friends  should  l,o 
clearly  instrneteil  that  the  course  of  eonvalescenee  is  not  Ic-s  de|ieiident 
ii|>oii  strict  ohedienee  than  is  that  ot"  the  previous  >la;re>. 

In  lied  the  convalescent-  should  remain  a>  (piiet  as  ]io»il)|e  and 
avoid  sitting:  up  too  lonj;,  particniarly  iti  the  first  jiaiT  of  the  alelirile 
p<riod  (eolla|ise).  With  rei.'ard  to  the  mental  >tate,  they  -hoiild,  so 
loiifT  as  possihlc,  lie  kept  away  from  severe,  particniarly  t(Mhnical,  lead- 
liifT,  while  lijrht,  indilVerent  literature  may  he  read  to  them.  Visits 
also  shonld  lie  restricted  dnrin^r  convalescence,  and  onlv  snch  |)ersons 
•'dmitted  as  d<i  not  excite  the  |)atient  and  do  not  cncoiiratre  him  to  par- 
ticipate actively  in  the  entertainment.  IIow  injnridiis  snch  visits  mav 
he  is  shown  in  hospitals  hy  the  tcm|>eratnre-enrves  of  convalescents  on 
the  otlieial  visitin;:-  days.  It  is  a  iisefnl  and  a  welcome  snhstitnte  for 
iniidi  that  is  forliiddcn  to  hrinj;  the  coinalescint  in  lied  into  the  open 
air,  if  the  weather  is  f:iv<ir:d)le. 

N\  hen,  after  convalescence  ha-  lieeii  c<im|>leted.  the  usual  activi- 
ties may  he  resnmed  cainiot  he  determined  in  general,  hut  tnnst  he 
decided  accordinjr  to  the  individnal  ease.  The  nature  of  the  atta<k  that 
has  heen  pass(^d  throned),  the  character  of  the  occupation,  thi'  coiistitn- 
tioii,  and  other  external  social  conditions  (ilay  the  decisive  rnlr  in  this 
connection. 

I'ersoTis  in  fa\i'ralilc  pccnni.ary  circnmstaiiecs  mav  lie  recomiiiended 
til  take  a  loiiir  holiday  liefore  rcsnm])tion  of  work.  l'"or  this  purpose  it 
is  licst  to  select  a  modera  e  nioimtainons  elevation  or  a  mild  seaside 
;:'S(>rt.  Cunsiilcralilc  altitndcs  (ahove  ]()()()  meters)  or  riu^oroiis  sea- 
baths,  particularly  in  the  ( Jerman  S(>a.  are  in  p'lieral  to  he  interdicted. 
In  winter  a  residence  in  the  South,  in  Southern  Tii'ol,  at  the  upper 
Italian  lakes,  or  the  Kivicr;i  is  .ippropriate.  The  Isle  of  Wi^ht  is  also, 
imder  certain  circmnstance-,  a  snitahlc  resort  for  recn|ieration.  Those  of 
moderate  means  should,  at  lc;;-t  after  severe  attaeks  of  tyjihoid  fever, 
spen<l  some  time  in  the  eoimtry.  The  ctliirt-  that  are  liecominir  more 
and  more  evident  to  provide  for  th(  less  well-to-do  clas-e-  liv  the  erec- 
tion of  sanatoria  in  the  eoimtrv  are  to  he  eordiallv  welcomed. 


i 


m 


TYPHUS   FEVER. 


|!    'I 


r 


l^■■^^ . 


t*- 


III  II 


TYPHUS   FEVER. 


:i)i 


TyI'IUS  fevkI!  is  an  acuU'  iiitiMtidiis  iliscasc  tlu>  liiilicrto  undis- 
povcml  cause  of  wliii'li  repnMliices  itMlf  oxclii~ivily  in  tlii'  Ixxly  «'f  tlic 
individual  atrcctud.  Tlu'  disease  ori<rinates  and  spreads  unly  hy  eontaet 
eitlier  direotlv  with  tlie  patient,  or  indirectly  with  a  tiiird  person  or 
with  an  inaniniato  ohjeet  int'eetod  with  the  ;.'erins  of  the  disease. 

Beini;  exeeeding^ly  eontairious,  it  i-,  therefore,  usually  epidemic. 
Oecasionallv,  when  the  external  or  pernpiial  eireinnst;inces  of  the  popu- 
lation make  It  ditlieult  for  the  eontaijiurn  to  obtain  a  foothoUl,  or  when 
the  proper  propiivluctie  treasures  have  been  carried  out  in  {jood  season, 
it  may  be  endemic  or  .s|)oradic.  Typhus  fever  '  has  no  connection  what- 
ever with  tyi)hoid  fever.'  It  belongs,  in  fact,  to  another  group  of  infec-, 
tious  <lisca.scs,  the  acute  exanthemata,  which  it  resembles  in  the  extra- 
ordinarv  ease  with  which  it  is  transmitted  t)y  direct  contiict  from  one 
individual  to  another,  by  its  self-limited  course,  i)y  the  rare  occurrence 
of  relapses,  i>y  the  peculiar  character  of  tlie  temperature-curve,  and  by 
the  fact  tiiat  the  characteristic  eruption  appears  at  once  instead  of  in 
successive  crop.s. 

HISTORIC 

The  plan  of  this  work  docs  not  include  a  detailed  description  of  the 
history  and  geographic  distribution  of  typhus  fever.  These  subjects 
have  been  c;»refully  treated  by  a  number  of  authors,  esjiecially  Murchi- 
son  and  August  Hirsch,  and  tiieir  description  is  so  complete  that  later 
writers  have  done  little  more  than  cpiotc  from  their  works  without  add- 
ing anything  of  their  own. 

Tviihus  fever  is  one  of  the  diseases  that  were  probably  known  to 
antiiiuitv.       It    is    possii)le    that    even    Hip])ocrates '   encountered    the 

'The  syiuinyms  f..r  typhus  fiv.T  arc:  SpotteJ  typhus,  pxunthcniatic  typluis, 
typhus  contasjiu.sus,  foliris  pi-tili'ii-.  tVUri-  putridii,  febris  petoohiiilis,  morbus  pulioaris, 
typhus  cari'iTuiu  (jail  fever  i.  f.'l.ri-  hi'llka,  fehris  oastrensis  (oamp  fever',  febris 
Tiautica  iship  fever),  sliip  tyjihus,  liuiiL'er  typhus,  and  feliris  Iluncrarioa  '  Huiit^.irian 
fever  i. 

'  The  term  tvphus,  as  well  as  other  names  by  which  it  is  knuwn,  sueh  as  spotted 
typhus,  exantheriiatie  typliu>.  petechial  typhus,  etc..  came  iiito  vo^ue  at  a  time  wher. 
the  disease   was  imperfectly  understood,  and  should  therefore  be  discarded, 

*  De  morb.  popul.,  lib.  ii.,  iii. 

4r» 


f  '."KS 


476 


TYl-llls  I  EVI.Ii. 


m 


(li^t•;l^l■,  MTnl  -unic  iM\-('-tiir:it'ir-  riaiiii  tn  have  f'niinil    passajjos  tlint  s<'<'m 
to  I'rtcr  ti]  it  ill  llic  \\iitiriif-  111'  Actiii-,   l{|ia/(-,  ami  A\iccnna. 

'I'lic'  cai-lic-t  iimiii-lakalilr  ri|i(irl-  date  I'ruiii  tlic  ijiidillc  a;:c.-,  aiul 
air  liy  iiiaiiy  aiillini-  a-riiliiil  [>>  .laiulm-  ilc  I'arlilm-  (  1  ItJ.'!)  and  the 
(i<Tiiiaii,  Atcriiiila.  Ililurc  tlial  date,  and  t'nr  -dini'  time  atUM'ward,  tlio 
(li-ca-c  was  cuMtMiindcil  willi  criTain  ciiidcniic  intictions  (li>cascs,  csix^- 
cially  llic  jilaiiUr.  'I'liii-,  tlic  ••  |ilairii'' "  ( |it-l  i  wliicli  (iriL'iMalcil  in 
C'v|iriis  in  tlic  years  1 .")( i:,--_'H  and  nivairt'd  alnid-t  ili<-  wln.lc  .it'  Ital' 
was  iiiidniilitcdly  ty|)lius  t'cvcr  ;  liii>  i-  |)iiil)alil\  tnic  al-n  nt' the  dist';..-~e 
called  iniirhiis  J luni/diii-ns,  wiiirli  I'aired  in  the  arinv  iil'  f'liarles  the 
Fitlli  diiriiii;  tlie  -iei^e  (if  .Met/,  in  the  yi'ar  I  J •"»•_'.  I'he  a|i|ieaianet'  of 
the  disease  in  Italy  at  that  time  I'miiid  a  hi-toiiaii  in  I'laseatoriiis,  to 
whom  i-  line  the  credit  tor  the  first  liieid  de-eri|ition  ol'  tvphiis,  ixi.-i- 
tively  di-tiiij^nii-hiiii,'  it  I'roni  other  di.-eases,  e>jieeiallv  the  plaixne.  He 
calletl   it   iiinrhu.i  /rnlicu/dri.i. 

Hildeiihranil  lielieves  that  a  nnnilier  ot'  other  dixa^es  de-ittnated  as 
the  |ila<;iie  (|.esli  in  the  sixteenth  and  seventt'eiitli  eentiirie>  were 
lind(;iil)tedly  epideinies  ot'  typhus  t'ever — as,  for  instance,  the  plaf.Mie  in 
iliiiiixary  in  lo"))! — t'l'hris  1  Iiini;arica  or  paiiiKHiiea  ;  the  phifrne  in 
Mei--eii  in  loTl  ;  the  plai^iie  in  l)eninarl;  (  I  ti  I .'!— "I'J)  ;  and  the  pla<;iic 
in  U<y(leii  in  ItifJlt.  Niinieion^  other  e])ideiiiie>  o|'  later  times — as,  for 
iii>tanee.  tlie  "  Funljii'hrr,"  rep"rt<Ml  hy  I  laseiiiihrl,  that  raffed  in  and 
about  Vienna  in  the  year-  I  T'lT  and  ITolt,  ami  the  epidemic  <"if  "/•;(!(/- 
Jif/iii"  that  -picad  overall  the  ( ieniian  provinces  in  1771  and  1772 — 
are  with  reason  reirardeil  hy  the  same  authoritv  as  I'ou'dr/ious  ti/jilin.'i. 

In  ever^•  century  typliiis  t'ever  has  t'ollowed  in  the  wake  of  armies. 
Diirini;  the  thirty  yiar-'  war  it  claimed  more  victims  than  did  the 
weapons  of  the  <'ontestants.  It  was  the  ierror  of  the  Napoleonic  cain- 
pait;iis,  and  decimated  the  I'rcnch  army,  alr<ady  demoralized  jihvsicallv 
and  morally  hy  the  tcrrihle  retreat  t'rom  Moscow. 

After  the  canipaiL.'-ns  of  1 7!i.'!  and  17!'l  the  s-eoiirgc  visited  the 
whole  of  (iermany.  In  1  7!l<i  and  17H7  it  hroke  out  aj^ain,  and  afttr 
the  jrreat  cam|iaii:ns  of  the  y(>ar  ISO"),  it  hecame  e|>idemic  throuf^hout 
(iailicia,  Himirary,  and  tlie  .\ustrian  crown-lands.  The  writinjrs  of 
Rennehanni,  Schiifer,  Ilecker,  h'asori,  Larrcy,  Ilnfeland,  Horn,  and 
especially  the  famous  monoi:ra|)h  of  Ilildenhrand,  which  to-day  stands 
as  a  pattern  of  epidemiolojry,  ref(>r  to  the  ahove-mentioned  e|)ideraics  of 
the  end  of  the  eiirhteenth  and  tlie  heLdniiinjr  of  the  nineteenth  centlirv. 

After  IS.'JO  the  disease  ahatcil  ^n  the  Kuropean  eontineiit.  iiotahlv 
in  <  iermany,  while  in  Irelan<i  and  Enirland,  where  the  disease  has 
always  heeu   j)revalent,  it  continued  uuahate<l  and  occasionally  broke 


iiisninn: 


477 


out    ill   oxtciir^ivr  civi.lfrr.i.-^.       I'l^ru    1  s  1 »!   to    ISIS   th,.  di^ra.-r  m^od 

till ir|i(,iit    KriL'laiiil  anil    Inlaii'l.      In   1  i<lan<l  alone  an  ii<_'litli  part  <.r 

the  ciiiiiv   |Mi|.ulati..n  was  all'crtiil,  ami    in    Hnlilin   a-   many  as  a  tliini 
oftlif  iiilialiilants  were  attaoUnl.      Over  4(t,(UH>  dcatlis  wire  r  cDrdcil. 

TliP  vcars  I  Slid  and  1S-_'S  ay:ain  witncsxHl  severe  cpidcniiis  in  hotli 
countries.  In  tlie  iliirlies  Ireland  -utVered  nio-t,  and  in  the  h.^inninf,' 
(if  tlie  t'(illii\vin<.'  decade  Scdllaixl  iliielly  wa-  attacked.  In  iSlC,  tlie 
vear  of  famine,  an  nnii-ually  -ever"  e|iidemie  limke  out  in  Ireland,  ami 
this  was  carried  to  iCnirland,  where  it  reached  il~  hif:he-t  ](oint  in  IS  17, 
and  continued  until  the  end  of  the  tMlowiiii:  year.  It  is  a  tliet  thai 
seems  incredilile  that  <lurinL'  'li:it  I'ine  more  than  1  ,(MMi,(HH)  ea-e-  of 
tv|ilins  occinred  in  Knirlaiid,  and  more  than  iJOd.OdO  in  Irehuid 
(Mnrehi-on  i. 

l)iH-in!i  the-c  i\so  decades  tin'  opinioii  that  t\  |ilms  hail  Keen  periua- 
iientlv  -n|iei-eded  i)V  ivphoid  fc Acr  uradiially  grained  ;.rrMiind  in  ( ler- 
inanv.  Thi-  iliiwion  \va-  di-|iclled  iiy  the  e|iideniic~  ot'  i  s  IT  and  is  ts. 
rpiier  Sile-ia  in  IslT  wa-  llie  tir-l  lo  -ntl'er  a  -e\eri>  outhreak  ot'  the 
di-ea-c.  To  Vir(  liow  we  owe  a  cla--ic  de-<-ri|ilion  <if  liie  epiilemioloi.'-ie 
and  social  conditions  ot"  that   peiiod. 

The  later  war-  of  the  nineteenth  cenlnr\.  \\kf  tlie  campaii;ii-  of  the 
fir-t  Napoleon,  wcv  characteri/ed  hy  ihe  appearance  of  the  -ciiir^c. 
During'  the  Crimean  war  it  decimat<il  hoth  the  Krinch  and  the  I'.ncii-h 
armies,  e-|)eciallv  the  former,  a-  c\  en  at  that  lime  hyi:ieni<'  mca-nrc- 
wci-e  far  hcltcr  nndcr-Iood  and  carried  oiit  in  the  J-JiLrli-h  camp.  l-"rom 
the  ( 'I'imea  the  di-ea-e  wa-  carried  into  l-'rani'c,  w  here,  a-  in  <  Icrmany, 
the  people  had  iii>  to  that  time  -up|)o-ed  that  they  vu're  -eeine  I'roni  the 
disea.-e. 

The  Italian  campaiiin  of  I  SCI  and  the  Tnrko-Kii  — iaii  warof  1S"S 
eontrihnted  a  mmilii'i-  of  \ictim-.  .Imluin'.;'  fi'om  Micliaeli'-  de-eription, 
the  sanitarv  condition-  in  the  Ku^-ian  army  mn-t  ha\c  liccai  appallinir, 
an<l  far  worse  even  than  dnrinL^  the  < 'rimean  war.  AecordiiiLr  to  this 
author,  of  -Jdit.ddO  patients,  at  least  ■")<!  |ier  cent,  were  atta<'ke<l  l>y 
tvi>hns  ie'\er,  and  half  of  those  attaekeil  -uccnmiie<l  to  the  di-ease. 
I)nrin<r  this  cpidemii-  tlie  snrireons  were  the  worst  sutTerors,  the  nior- 
talitv  amontr  them    rcai'liiin:   'i(i   per  cent. 

Dnriiiir  the  l''raneo-l'rnssian  war,  on  the  other  hand,  the  armies 
retnained  entirely  free  t'rotn  typhiis,  thus  MlTordinir  a  strikiiiL'  proof  that 
the  disease  is  caused  not  so  much  hy  the  ma-siuir  anil  mohili/ation 
(if  larire  mimhers  ot'  men,  as  hy  their  eoiitinned  pri'senee  in  reixions 
where  the  disease  is  either  emieiuic  or  liaiUJfiis  to  he  nijrinsr  at  the 
time. 


b 


WBi 


(.•^. 


lYriii  s  iiiii: 


In  l''r:iiir,..  uliciv  tlic  ,li~,.:,-.-  1,:,-  n.v.r  i:i!,,..|  ;,  ii,.,,,  i;„,t|i,.|,l,  it> 
rvr,i,i  ,i|,|.,;iran.r  :i-,i,i  ,|.Mru\,,|  ||„.  il|,i-i..n  i|,;,t  ImvimIi  -,,il  ua-  ii..t 
ti.vonil.l.'  i.Mi,  ,|r\v|.,|,„„.„,.  In  |.s;»,;;,„  ,.|,i.|,Mii,'  l,r.,k,.  ciii  in  i.ill,.. 
The-  .li-.a-(  ua~  r:mu;\  l,,  ||„.  |,ri-..i,.  ,,r  Pari-,  «|i,  ,i,-c  il  -|„va.l  In  il,,. 
<  ily  and   -iii'i'.iiiiii|ii|._.-. 

\tl.r  III,'  ,|.i.|,nii.-  ,,f  1SI7  aii.l  |s|s,  t\  pliii-  Wsrv  .■,,iil  iii,„.,l  (,, 
liii-.r  III  rcitaiii  n-iun-  of  ( I,  ii,ian\  until  t|ii>  iM-iiiniiii.  ,,f  tli,.  ci-litic-.. 
•'^""■''  '''•"  'il'"'  i'  li:i-  Ihvoimc  .11, 1,11,1. •  ill  l'|.|><l-  ^il<-ia.  Mli.l  in  |,MI7  it 
.•MaMi-li,.l   ii-,lt    1,1   KaM.rii  aii.l    W.-i.ni   I'ni-Ha.        Tli..  ,li-.a-.>  i-  fi.,| 

" -'sillily    tr,.Mi    ill.'    II,  i;;|,l,.,riiiM     r,,|i,|,    |,r.,\iii,.,.,    ,,f   lin-Ha.  ami    at 

iiiliT\al-  il  iii\a,l,-  (i,  iiiiaii\,  li-av,llii|M  i,,  a  ,|iiv,ti,,ii  Cn.iii  i'n>\  to 
u.-l,  an.!    -iiiva.liii-    ,,v,r    ih.^    ,  miiv   .■..imii^ .       |i    i-    t.,    !„'   ,.I,-.,tvc.|, 

''""'■^'■''-  '!'■"    '!"■    iiiliii-ils   an. I    .li-iril,iiii,,n    nf  lli..   .ii-.'a ..iiMaiitlv 

«liiiiini~li  in  ill,'  -.■ .liiv.'ti an, I  il  i-  ,,iil\    in  lli..  .a~I,'iii  |M,rlion-  .,f 

(i.Tiiianv,  |,aiti.'iiiarly  in  ili,.  lV.>iiii,  i-  ,li-iii.N,  thai  lai-,.  ,n,lr.ni.'  ,.r 
«|,i.|.nii.-  ..iiilavak-  ,,rrnf.  \\|„.|i,  i,,  d,,.  year-  jsiiT  and  lS(;s,  ti,,. 
di-.av  ua>  .arii.'.!  int..  KaM.rii  an.l  W.-i.tii  I'm-ia  i.y  va;;alM,ii,i-,  it 
.Mv.ll,,l  t.,  ,.n.,nn.,ii-  •■i.i.l.ini,-.  Tliii.,  in  ih,.  .ji-tii.-t  .,f  ( Jiiinl.iiin.ii 
al.,11,.  |(l(i(»,,i„.^  XV,. ,v  n.|„,rl,.,|  ((iiiti-ta,lt).  Ki.iin-  lli,.  |„.ri,„|  in.ni 
|S7.",  t,,  lSS:i  th.'  ,'a-t,Tii  |.invin,',-  and  pari-  nt'C.ntral  (nrinaiiv  ui'iv 

vi-il,-,l  liy  a  -rvrv iJMvak  of  l\  pliii-  f,.v,r  ;  mii,!  dnriii;:  tli,.  (iv,.  y,.ars 

from  I.S77  t,,  I.s,s2  (iiitt-ta.lt  iviH.itcd  I  (i.iKKl  t-a.^'s  admittc<|  f.  tlie 
l'ni--i,in    li,i>|)iial-. 

'"  ■'"  ''"■  ' •"   ••\t,n-ivc  (■|iid..nii<'s,  iJcriin  ami  tlic  larger  .'jtio  ,.<' 

Noitli.a-tcrn  an,l  S.,ntii,aM,rn  ( i.rinany,  -iicli  a-  K;ini--l.(.rjr,  Stcitin, 
I).lll/iL^  I'.n-laii,  ,l,.,  u,r,.  iiiva,l,Ml  t.i  a  irivat.r  .,r  los  (..Merit.  In 
•  ■wrv  .'a-..  tli(.  a|.|,r.,a.-li  .,f  tli,.  .li-ca-f  \va>  fr,.ni  lli,.  i-a>t,  and,  t:,rtii- 
iiat.ly,  it  ii..v,T  sn,v,.,.,|,.<l  in  ,,l,tainiiiL^  a  p.rinanint  t;.,,tli,.l<l.  In 
r-crlin  |iarli.nlariy.  afti.r  I.s7(l,  llic  ,li-,a-,.  a|i|Marvd   aini.,>t  cvi'iv  v.ar, 

'■'""i"?-'  ii-nally  fr Ka-I,rn  .aii.l   \V,-tcrn   !'rn^>ia  and    I',,nM.rania.  the 

fii-t  -t,i|i|iinii-|ila.v  ..f  til,.  (•|ii,l|.nii<'  .m  it-  in.iivli  fnun  <a>t  t.i  w<.>t.      It 

^1"''""'  ■' "ir  'li''  ''l:!"  "f  iiili.aliit.aiit-  I.y  \vii,.ni   it    i-    ii^naliy  i-arri.nl 

lli.at  i-,  va-al...ii,|-.  an.l  |.,iv,,„<  ,,iit  ,,f  „.,rk  an.l  without  <li(.ltcr. 
♦'haritaiil,.  in<tiliili.iii-,  |.ri-oiis,  ami  tli,.  |,,u..-t  vari.'ly  ,,f  inii>,  known 
:i-  -[..n-'"  (I'.iim.n).  u,.r..  the  .•liief  t!..'!  ,,f  the  di-ea>e.  The  heller 
I'.nt  of  tlw  [...|.nlati..n.  ih.,-,.  who  ]..,-.-,■<-  a  pennaneiit  d<.niieil...  weir 
;ittai-ki><l  only  t.,  a  v.ry  -li-ht  ..xtiwit,  ami  tlie-e  .-ise-  eoiiM  aliii,.>t 
illway-    he   trai'i.l    t,.  dir.'.-t   eontact    with    tv|(liii>    |.ati.'nts. 

Diii-iiiir  the  |..'ri,,.l  fn. Ill  l.s7ti  t..  I.s7;i  I  w:i-  Mi|.eriiiteml.nt  ..f  th,. 
I5.Th'ii  |.,.-i-lioii>,'.  th,.  la/ari'ti..  in  M. .al.it,  and  then.  eiij,.y...|  ahundant 
<'|.|.,,rtiinity  for  stii.lyiiiir  the  .lisease.      I    haw   the   rejM.rts  of  (177  ens...- 


Ills  I  < line 


I7'.» 


iliitili"  U<>\\\  til  it  lliiii'.  I,:itcr  I  -aw  :i  tin  -jioruilii-  i:i-'-  iTi  1  IiiiilnirL' 
ami  lii'lpsic,  l.iotiL'lit  !>>  '•nii;:niiii-  Irmri  I'i.ImihI  iiikI  llii— i:i.  Tlir  ImI- 
luuiiiL'  (l(-iTi|.tiiiii  ol'  ihr  ili-c:i«c  i-  Km-iiI  mi  .1  -tiiily  ul' tlii«c  ('iiiilrriiics 
ainl  111  a  tiiiinlxr  nl"  -|Mii-;iilic  (ii-c-.  ..<■(  inrintr  rliii  ll\  III  my  |iri\alc 
iinctin',  tli:it  wire  111'  i-|«i'<ial  im|M)rUiiiii'  rnuii  tlic  >taiiil|xiiiit  of  ditliT- 
ciitial    <lia;'iiii-i>. 


i 


L  A'^  :- 


S'f^.' 


E T I  O  L () G  Y. 


¥^ 


;:ii, 


^i^ 


ORIGIN  AND  MODE  OF  TRANSMISSION  OF  THE 
CONTAGIUM. 

'I'M'III  -   I   i;\  i:i:  i-  ■  ..|    {\u-  MmM  .  ,,MIa-ioii- ,|i-,.;,-.c<  klinwil  tMlllcdi- 

•  ■iiir.      Il  ,,ii-iii:ilc-  ;iii.|   -|,iVM.|-  tn  |,n,li-|„,-,.,|   iii,|iv  i,|ii:il,  „,|,.U    |,v   ,1,,, 

.lir.Ml    ..;•       M.lilV.I      l|:|I|-.|lii"iMt|    ,,r    ||„.    -|„,  ilir    ,,,|||,l^inill,    .1,  \,  |,,|,1||M    ill 

'i"    '"■•',■•     ■•'  'II''  I'^iliiii'.       I'll''    uii'i\f   ,.|'  li',in-iiii"i..n    .111.1   ,  iilr;iii.-.-  ,.(' 

thr   cnlil^i.jiillll    ll'ln    ill,'    l...,|\  .    :,||||,,l|._.||    n,,t     .-I-     \,.|     .irrlllal,  K     1,111. \MI.    i^ 

::ii.|..iil.|..|l\  ih  all  ,--,iiiial-  -iinilar  |..  tlial  wlii.-li  ..[.lain-  in  iIm  a<-iil<' 
rxaiilliirjiata  — -inall-|...\.  -i-arlcr    tlsir,   in.a-l.-.  .  !.■. 

Til..  |,.,--il,llii\    ,,|    il nia-iiiMi   ..I' l^  |,l,ii-   t.  \.  !■  .,ii-ii,atin-  ..nl-iilr 

and  iii.|.|.,  n.l.  nll\  ..t  ili..  1,.m|v  ,,f  ij,,  |,aii,ni  i-  n..  tii..ir  .■,.n.<i\al.|f 
tlian    i-    ill.'    -|i..iiian.-..ii-    |>i...|ii.-ti..ii    ..T  i\  |,|i,,j,|    ti\|.|'. 

''""-■■'-"■  'Il  'I  'ii'i'-  "lull  :i    -|..iali.'  ..li-ih  ..1   i\|i|iii-  fiMi-  \\a-  .'..11- 

hi.lcnMJ  |,.,.-il.l.  aihl  iwii  usual,  llir  .  ..ula-i..uMi. ->  ..I  lli.'  .li-.a-e  in  ilio 
lii.i.l,a-ii  >,u-.'  wa-  U|.li.'|.|  l.v  a  f.  u  |.|,\ -i.-iaii-.  u..nil.lv  \<\  I'lU.M.  uli..  ua.- 
i;ir  ill  a.jvaii.i'  ..l  lii>  liiii.-.  Hi-  h  :i.liin->.  Ii..\\.\  ,i .  w,  i,  'm.,i  al.K-  l.i  .li-|.,l 
I'lilii-cly  llio  lIuM.rv  ,,f  mi.a.-iual  i.'  ..iiLjin.  u  liidi  .-iivv  i\  c .'  imlil  a\.i-\  mu.li 
Int. T  .late.       .MuivliiMii,   liJMi.-.lt.    uhi.  a.kii..uli.l-..|    ilial    I  la-  . ->,  ul  i,a  I    [...ini^ 

in    llir   .li-,a-.'    aiv  llic    -|.,.  ili.  iiv  ..f  tl,,.    |„,i> ni.l    i>  r,  |.r...lii,ii,,ii  in  llic 

l)ii.ly  ..f  ih,'  |.ali.iil.  .l.\..|,-  >..i,,c  >yAvv  I..  il„.  |,(,>Ml,iiiu  ,,|  an  iii.li-|..n.lciil. 
Fix.nlaii.'.,ii.- ..ri.'in.  a  lli...n  llial  i\,ai  (  ,,'i.>>iiiLj.T,  uilii'all  lii>  a.'iinicn,  .l...s 
net  .|uitc  viMiliin-  I.,  .Ji-.'ar.l.  lie  l„li:..  ,.^  lli.al  in  miv  .ii.ms.  i>|„cia!l\  hIuii 
llic  .lisi.a,-.-  !.n-ak-  ..iit  in  i-..|al,-.l  |.|a<'.-,  a.-  ..n  ^lli|.|.nai•.|.  In  |i|-i>..ris.  'clc.  in 
the  iilisciicc  of  l\  |iliii>  paliiait.-.  ••  i-c-.mr.-r  iiin^l  I  .■  Iia.1,1..  llic  hI.h  iirc  nalin.'* 
of  llu'  niia.-ina." 

LniiL^  after  ( ;ri.'>.-ini:<T.  .lai-ciuil  '  inainlMinc.l  tliat  ,-|i..niaih..u..  |,r(..hi(ti..n 
was  |..i>sil.K'  iin.l  ..ciairrcl  ii..t  infrc.|iuaiiK . 

Ill  .jiiit.'  i-fCfiit  tiin.,-  K,I>.||  aL:ain'>li..vu.l  a  IcaniiiL'  I..\\ar.l  tlic  same 
flic.ry.  liclifviiiL'  tlial  .Ti-iain  inn. ..u.. lis  i.'.ian>  in  thi'  I.m.K  mav,  iin.ItT  Miil- 
aliii'  rxli-rnal  (■..n.lili..n-.  assume  a  ltiiiI  -|m.  iti.-  \  iriili'ii.c. 

Ouiiiir  1. 1  liir  I'Mivnic  facility  with  uliicli  llii'  .li-ca-c  i-  .•arric.l  fr.iiii 
iiidiNiilual  t.i  iii.livi.lual,  >|i..railic  .■a-.c-  ..f  t\  |iliii-  lc\.r  arc  \  crv  rare, 
'llic  ili-casc  is  aliii..-!  alway-  cii.lcniic  ..r  ili-tiiic||v  c]ii(|cinic,  ami  under 
iimi-m.lly  fav..ralilc  .■..iiditi.ni-,  c-|ii'cially  uli.ai  lai'tre  iiiiiiilicr-  ol'  men 
nrc  massed  t.iL'ctlier  in  -..cial  ..r  milit.ary  d.-titiiti..ii,  llic  nmiil.cf  i.f 
individuals  attacked  i>  rarely  eiiiialled   .r  exceeded  hv  aliv  of  the  Mtlicr 

'    ',•./.-.     //.v.     1K7,-;     .,,1,1     /■„/,,/.     hit..     \S". 

4sn 


t'TtOLOOr. 


Ml 


itilfctiiiii-  ilis(;i-f-.  riic  iiii.-t  I  \lin-i\i  I  |iii|(iiiir-  arc  uli-i  i\i  d  \\  licii 
tlir  <ii-('a~('  i-<  carricil  rrniii  a  i'(iiiiiii'\  win k  ii  i~  t'lulciiiir  iiitit  u  ili^trii-t 
ii-iial!v  tree  tiiiii.  I  111    ili-ca-i  ,  ami  wliiili  iIki'Ihk- ihn  '  iiofjsi'-      inv 

iiiimmiilv  •  iir,  i-ntiv  cr-«|\ ,  wIkii  'ar;.'c  iKitiiln  r-  ul  iiiciIi^iximmI  inii- 
\  idiial-  tra\il  Irnm  -ihli  r(;.'iipii.  to  ((iiiiiliii-  ulicic  llic  <li~ca.-"  is 
eticliiiiii  ,  a-   ■Miiii-    ill    tiiii;;ialinii    111-  cluiiiii.'-    war. 


GEOGRAPHIC 

I.'i  i('i::ircl  tn  tin-  iinliiiiir  <li-triliiii ioii  ami  |»rtiiaiiciicc  of  tvpliU'^ 
t'lM  r,  JMiijIaiKl  ami  liilaiid  i"rii|>y  llir  lii-t  |i|a<t  aiiHiii^' tin  rmmtrio 
"t  i'liipipf.  riif  ili-ra-f  never  ilii'~  inil  riiin|ili'ttl\  in  tiic-i-  (■(niiitrics, 
wliiTc  it  i-.  till'  |>r(iliiiiiiiiant  t'cirni  ul'  ••  1\  |iliciii|  "  di-ca-c.  'I'lic  di-(a,--o 
i-  (Mca-iniially  .arricd  t'lniii  llic  -h.iii-  ol'  Inland  and  l',ni.'l:ind  t'> 
iicii^liiMiriMLT  iMuntrii'~,  |iarti(nlariy  in  inunfic-  witli  whicli  l-liiu'land 
maintain-  an  arli\i'  iiiinincr<aal  iiitcri-nnr-r,  ami  lliat  arc  ii-iialiv  tree 
Irniii     tlic    ili-(a-c    and    t'lurn    tlic    cnndilioii>     that     liixor    it-    l)c<iiininj; 

endemic.      Siicl inlrie-  are  Sweden    and    N'irwa\.   l>eii.dnm.   Ilnilaml, 

Norlli  Aineiiea,  and,  tn  -nine  e\teiit,   l'"raiie(  ,  wliitlicr.  duriiii:  llii-  <en- 

tiiry,   tile   di-ea-c    ha-    rrcijiieiitly   I n    carried    I'rnm    nthcr  I'nnntrje-   a- 

wcll,  iinlalily    iVnin    l;n--ia. 

Willi  llie  e\i'e|)tinll  nt'  :i  t'cw  di-tlicl-  in  tli.^  Sniilliea-t,  -ncli  as 
r|i|ier  Sile-ia,  (  icrmany  i-  ii-nally  (|iiite  tree  fmiii  the  di.ca>e.  When 
an  niilid-cak  nccnr-,  it  i-  alnin-t  alxvay-  dciixcd  fmni  the  e:i-lc;ii  c(jim- 
tries,  c-|)eeially  l{ii  — ia,  in  many  pari-  nf  which,  |>artienlarl\  in  tlio 
Haltic  .nid  i'nii-li  |in>vince-,  iintnrtunatelv  'iir  ( iermair.  ,  the  di-i'as<'  is 
t'lidcmii'. 

In  liiiiiirary,  'i'nrki  y,  and  the  adjninini.'  Oriental  cnnntrics  the 
(li>ea-c   ap|iareiilly    never   iMM'umes.c|iiite   extinct. 

N'ariniis  parts  ..f  Italy  have  liecii  visited  r<'iMat('<lly  bv  oh-tinato 
epidemic-  (if  ty|)liii-  fever.  It  has  appeared  in  I'icninnt,  Tnsennv, 
Naplc-  and  it-  -iirmnndin--,  Sicily,  and  Sardinia.  In  the  two  last- 
named    i>laiids    the   disea-e    seem-    never   tn  disap|M'ar  entirelv. 

Spain  and  i'ortii^ral,  nwinn^  tn  their  u^c(iir|-;,|,hic  pnsitinii,  are  rela- 
tively free  frnm  the  disea-e,  althniiirii  mild  niithreaks  have  oconrrod, 
the   last   niie   in    I'nrtmral    in    ISSO. 

In  Atrica  the  diseaso  ha-  Iwen  observed  ehiofly  in  the  maritime  por- 
tions that  carry  nn  an  active  trade  with  Kiiro|«-.  In  .Mtriers,  where  it 
ap])earcd  fnr  the  tir-t  time  in  the  early  si.\ties  of  the  last  eentur)-,  it 
seems   to   have  lu'comc  endemic. 

Persia   and  ( 'liina   are   never   free  from  its  unwelcome   jiresonee,  tlip 


m 


f3'^i- 


«*>=«*-> 


482 


Tvriirs  ri:\-i:i;. 


.ni-.Tv  uii.l  M,iiM!..r  of  tlir  inlial.ikint-  furni-liin,- al-niulatii  ..pixirtmiiiy 

I'nV    tllC    iiccliri'lllcc    i.t     ilic    di-ia-l'. 

In.lia  aiipcar-  L.  U-  !vlat i vl_\  fivr.  Munlii-.M,  c.iiM  imt  .Ifti-rmino 
to  ln^<nlirr  -ali-ra.ti..,,  svlinhT  tlic  rrporl-  that  !„■  .•..Il,vtr,|  fn.in  tliat 
,.,,nntn  rrally  nllnv,!  to  iy,,liu-  tVv.T  -r  n-l  ;  tlu'  irport^  of  inofo 
riMviii    time-   aiv  al-o   ((iiially    iin-ati-tanorv. 

THE    NATURE  AND  MODE   OF    ACTION  OF  THE  TYPHUS  FEVER 

CONTAGIUM. 

■n„.  luiv-oiML'  ivniark-  on  ilir  -ro-rapliv  an.l  lii-tory  of  the  .li-raM- 
u'll  Millir,.  to -how  the  .nonuou-.litVciviKT-hrtwc.ai  typliii- aii.l  typlioid 
a.-  n-anl-  oritrin  anW  ~|Mva.L  Whnva-  tv|.hoi,l  frv.r  i-  f mud  in  ahno.-t 
all  th<'  rountfi.',-  u\-  thr  ranh,  a.'.l  i-  nowh..,v  Wi-tinrtly  rn.l.mi.',  this 
,,„alitv  of  ,.M,lrinicitv  i.  |.,ruliarlv  chai-aot.ri-t !,•  of  typhii-  f  vrr  ;  and 
Nvhrrei:-.  owiii-  to  ih,.  iiatuiv  an.l  ino,lr  of  -pivaW  of  it-  .■ontatiiuin, 
tv|.hoi,i  t'rv.r  -iv-  i-i-r  to  -ov,  IV  .pi.loinir-  only  nn.Irr  v,fy  -|.ccial 
r'inannMaiir. -,  and  o,.,nr-  al.no-t  alway-  -|,ova,liralls  or  in  .■i,vnn,-o,  ih-a 
Miva-.  th.'  fn-a.'ion-nr-  of  thr  typhn-  poi-o,,  an.l  the  caM'  with  \vh„h 
i,  i-  iian-i-ort,.!  lhio,|o|,  ti„.  air  hy  inaniinah-  .arrirr-  lra<l  to  rain.l  an.l 
ui,l,-|ava.l  <li-trilmtion    ..f  the  .li-ra-..  ulu^n,  in  a  -iv.Mi  ca-c,  it    i-    .'ar- 

,.•,,.,1  int..  a  n..n-inlivtr.l  intrs    wh..-.'  inhal.ilant-  ar.^  ,,r..ii-i...-.'.l  t..  it 

i,v  ini|,.'rf.vt  .l,A-.|..|.in.iit,  -tarvati..n.  ..r  th.-  n.i-.ri.-  ..f  war. 

Bacteriology.- -.Mth..n-h,  a-  ha-  l"vn  r.'niark.'.l.  we  ar.'  .|nitc 
certain  that  th.'  ...ntaLnnn,  ..f  typhn-  f.  v.t  i-  a  -|...af,.'  l...i-..i.  .'lal...rat..l 
S..1..K-  within  th..  h...lv  ..f  th..  pati.nt.  an.l  th.ivf..r..  nn.l..nl.t...lly  r.tcr- 
;,l,|,.",o  |.ath....vni.-  n.irr..-..i-ani-n,-.an.l  aith..uj:h  a  -ivat  .I.^al  ..f  .■atvfnl 
i„v,.-ti..ati..n  ha^  U'ru  Arv.uA  to  th..  Mii.i,...t.  ur  ar.'  -I'll  in  th,.  .lark  a- 


it-  |i|..'..i-..  liatni 


....       N..t  ..1 


,,t  on,' ..f  th..    nianv  niii.ro-.'f,Lrani-in-    hronuht 


In 


f,,rwar.l    np  t..   th..    i.tv-.tit    tiin..    ha-    iiain..!  .....ni.h.t..    r......._miti..n. 

tin-  r..-,„...t    th..  ,,ro,ln....r  ..f  tv,,hn-  f..v..r  .•l..-..|v  r,.-..,Mhh.^    that  ot    th.' 

a.ait..  .Aanth...nata.  whi.-h.  a-  uill    \<r  <l^•^^n    ,n..r..   an.l    n,...-..  ..hariy  ,n 

,!„.-,.    ,,a.r,.-.    ..xhihit    a    v.rv    .l.-r    -innlaritv  n.    tv,,hns    t.-v-.r,    h..th    in 
tlu.ir  ..ti..l..^v  an.l  in  th.ir  .-lit.i.al  Iratnr..-.      Ti.ir  ,.x..itin^  ..,„-.  -.  hk.. 
tl,.  ..a.i^-  ..f  tv,.hn-  f..v..r.  hav..  ..h-tinat.iy  r.-i-t..i  ..nr  ,.r..-..nt  tn...h...N 

„,•   |,;„.,..ri.,l.,-i,.    r.-.'ar.-h.  an.l    th.y   a,.....f.lin-ly    f.rtn    a    M"'"'^''    ^''""l' 

amon-   th..  a...it..   inf....tion-   .li-..a-..-.  th..    .■ti,,l,,._n-  ..f  whi..li    aiM-.-Mi-    t.. 

r,..,ni.v   -..in,,   ontiivly   Ui•^^    an,l    hitlu.ft.,    nnkn.,wn    n).th,..N   ..I     ii«v.- 

tiLiatioii. 

•n„,  ,l„,„,v  „r  th,.  .honn,.   natnr,.  of  t!i,.  l...i-on  .>f  tvphus  frvcr  is  at  th,. 

,,r..-..„t    tin,..    in,on.stin.   f^.r    hi-.^ri..    r..a.,n-   ,,„lv.      ^y--^'  ';:';;^   ;,  ^^ 

sw,,|.,.rl..r,  of  the  th-ory  ..f  a    .-a.,.ous,  nMnn.ana,.al    natnro  of  th.      tM.hu> 


i:iini.()(,y. 


483 


CMiiiaL'iiiiii  "  '  l.ifliiL'  ami  (illicr>  miiil'IiI  llicii'  >troii;.'c>i  Mnrmiiciit  in  llic 
|ic<iiliar  iiMiilc  III'  iiriiriii  ami  >|iri'a'l  "\'  tin-  ili.-riiM'.  Mm-li  iiiftTrf^t  attailns 
In  a  i-lia|ilcr  in  •  ii'ir.-siiii'fr  s  clas.-!''  uork,  wliicii  >lamls  a-  an  i'.\ani|ilc  lA 
im-i>ivr  M'ifnlitic  rcasoiiin-^,  in  wliidi.  al'lcr  a  carct'iil  anal\>i.-;  nl'  all  ihc 
flinldi'-ic   larli>rs,  \\v   i-ctulcs   tlir   llinn-y  nt'  lln-  L'a.-iMPUs   natnrc   of  llic  cdnta- 

t^iuni   aii'l   'li'<-larc.<   il--tlir   conlajiuni  —  Id   lie  i 'ii.siiilar   ami  (lu>t-likf   in 

i-haraclir. 

Ill  I'l'jar'l  to  tin-  variiiiis  llii'iii-irs  ailvamci.  «  Id  the  niiiTiipara>ilir 
natiir<'Ml'  ihc  l\  pliii-  roiiiaLium.  uc  >liall  |la^<ll\^■l•  llu'  i>iilaU'il  fX|i' .  iimnts 
III'  llic  lirsl  iii\  i'.-li:;alnr.-  ami  nslriri  iiiii>rlvi>  In  llic  ninrc  iiMportaiil  nt  llu- 
newer  roni  riliiilions.  \\  liirh  t'\  en  llie  aiillinrs  llieiiiselves  ilo  mil  alua\  s  <■' n- 
^iiler  i|llile  eoii\  iiieiliiT. 

Ill  l.ss.S  Mnreaii  aiMl  ('."•lie/  '  lieserilieil  a  liai'illiKs  resciulilini.'  ihc  Hlicrth 
liai'illiis.  wliieli  iliev  isiilaleil  Irniii  llie  IpIimp  1  ami  urine  of  palieiil.- ami  which 
ihev  reLTarilc'l  as  ihe  prolialile  cause  ot'  ly|iliu-  te\er. 

A  vear  lalcr  lllava's-  work  on  llie  poison  of  lyphus  fever,  liaseil  on 
inalerial  olitaiiieil  from  llie  I'raL'ue  epiileinic  of  I  sss,  aroiiseil  L'real  interc:-!, 
anion;:  ineilical  men.  Illava  exaniiiieil  4-i  caila\ers  ami  olilained  from 
alioiil  Iwo-lhirils  of'  ihem  a  peculiar  slrepIoliaeiHus,  which  he  was  alili  lo 
fiml  in  ihe  livinir  siihjecl  also.  althoiiLrh.  il  is  Iriie,  nol  wiih  the  same  con- 
slancv.  Ihe  niicri)-ori.'aiiisn!  was  foiiml  milv  in  ilu'  lilooil  ami  cnuhl  not  he 
isolaleil  from  the  orirans.  Illava  liini>elf  is  verv  .'uanleil  in  his  slateinents 
as  lo  the  speciiicilv  of  his  inicro-orLMiiisiii.  ami  ,-oon  aflerwanl  il  was  ilis- 
piilecl  hv  other  invcstiiraiors  i  Cornil,   ilalies.  ami  others  i. 

Ill  \X'^'2  an    important   paper  was  puMishetl   liy    Ix-waschew,"  who  foiiml 

iniiiiite,  very  rclVaciive. ■cus-like  corpuscles  in  the  lilood  of  typhus  palients. 

cspeeiaiK  in  that  ileriveij  from  the  spleen.  I'liese  were  toiniii  in  fewer 
nuinhers  in  other  portions  of  the  cinailation — t'or  inslanci'.  in  hlood  lake, 
from  the  lip  of  the  liiiL^cr.  Some  ot  these  corpuscles  were  proviiieii  with 
llaLiella  that  couhl  lie  siaiiicd  hy  l/illlerV  nielhod.  like  the  t!a!.'ella  of  t.ie 
Elierlh  liacillu>.  He  also  liiiiml  free  llaL'elia  without  aiiv  a|ip;ireiit  ediiiicc- 
lion  with  cocci.  The.se  rfpiroeheta'  exaiitheinatiea.  as  he  called  them.  Lewas- 
cliew  rcL'arded  as  various  forms  heloii'/inir  to  the  same  drL'niii.sm  and  iiidi- 
c.alini,'  dill'erent  staires  ot'  th"ir  lit'e-liistdry  and  develupment.  and  he  was 
stroiiL'ly  inclined  id  accept  them  as  iIk   cause  of  tvphus  lever. 

.Soon  aflerwanl  Thoinoi  and  Calmette'  ileelared  that  lllava's  niioro- 
iiriranism  was  onlv  a  secondarv  phciiomenon  without  aiiv  etioloirjc  sicrnifi- 
(•anee.  and  lirouirhl  ferward  a  new  cause  of  the  disease.  This  tiiev  desorihed 
as  a  tlau'cliate.  and  in  .some  case>  amelioid.  orLrani-m.  which  tliev  claim  to 
havi'  loiiml  in  the  sphaiic  hlood  o|'  ."i  liviiiL.'  suliject.s  and  in  1  ease  from  the 
pulmonarv  hlood  alter  death. 

Diiliicf  and  liriilil  '  descriUed  a  sni.ali  diplococcus  provided  with  a  ca|>- 
sule.  which   tliey  elaiincd   to   have  found   in   the  hlood,  hut  especiallv  in  the 


'   ■■  ('..iitrlliUl     ;i  I  .'lu.l.'  liil  typh,  c\;inlli   ."   <-,r:.   /,,/,./,    ],!SS.    y,,    L'S 

■'  ■■  Ktii.lc   -ur   1^'    t\|ili.    exiiiitli  .   ■    A)\-/,.    IS.J,;,i.r   ,/,-    »„■,/,.    lss;i,    T.    iii..    1.  an.l 

('.•iltruH:'      f.      li.tl.l..     IS'.lll, 

'■■r.-l"T.li.  \likiv.-orL';i,.l-iiM'ii  .1.-  Kl.-.'ktyplni-.'  I).;,i.,-I,  mnl.  \y,,rh..  ISlrJ. 
N'l.   |:l.      ■■  r.'liT  Ji..  MikM|.iini-il.'n  .1.-  Kl.-ktyphu-. ' '  /'-V  .   \,.    :M. 

«  ■■  N'..l.-  -ur  >|UrI(|u  -  .Aiiiihii.  .li'  -;in;.'il;iii-  !'•  lyph,  .■\:nith,.  ■■  .\  iiim/r-!  ,//■  /  h.^titilt 
l''i^''-nr.   IS'.I-J.  ;,n,|  Trnitr  ,1,-  ,„.  ,1  .  \.^  (  h.-.r..  ,t.    I! Ii:inl  .  t  l!ri^~iiii\.  T.  ii  .  p,  0. 

■•  I '.'iilrii.iui  :ii  .',  r.!ii,lr  .■di.i!.^;;;-^  palhMl,,^i,|in;  cl  baktOriohigi.jiiL-  Ju  typh. 
exuntll.   '  .l;v/i.  drin,,t.   Exp,  rin,  .    Is:i4. 


ii5i«  - 


^«^:- 


..►i"._ 


» 


484 


TVi'iirs  ri:vt:ii. 


air-passa^cs.  in  pulnH.„arv  lo.i.  an,l  in  the  .,m.m,  These  llu.y  .aui  -  c^  I 
el'i  l,e  ree.en  zea  «  hen  Maine.l  with  nu-thvlene-hluc.  he  nnero-r^^an- 
l;  -vvere  .mwn  on  vanon.  nn.ri.ive  n.e.lia,  a.  a.ar,  an.l  y.ehle.l  orunf:e- 
^^lov  eultures.  The  au.hor>  al..  helieve  ttu.t  they  were  ah le  by  ex,«.n- 
;:n,ul   il'oeuiation   of  .nin.al.  to   pn.Uue  a  eon.lit.on   re.en.hhng  typiu.s 

*''7-inaliv.  it   mav   he  achh,!   that    M,>if  !  nj:  ai:o  .le..rihe,l  a  variety  of 
„„„1     spiVUa   reswnhllM,    Le.uH.luwV   nr,an,.n,s   n,   the   hU..ul  of     yph 
f..ver  pa  ien,..  an,l,  lurlher,  that  '-  heeM  ,nan  .lawns  to  have  -hseovere.i  Mnall 
u,-,o.iU.   ha,.illi  Nvi.i>   rounae.l   eMre.ui.u.s.  oeeurr.n,'   ejther   u.  ,,a,rs  or  ,n 

ir    el  '.in<    «hieh  he  savs  he  uas  ahle  to  euhivate  on    hloo.l-sern,n   hut   n.;l 
^^.h   ;      amUhieh  he-.al-ea  .he    Haeillu.  san.nin>s  .vplu  exantheuwU.n 
(•;  have  a  v.-'itahle   .an-ple-ear.!  of  ha.-.eri.,lope  tMul.n,.s.  an,l  U  «.ll 

1,.   I         for  the  present   to  reserve  ju.lpnen..     t»ui.e  re,en.ly.  u,  tae.    n,en 

M  '  Vxnev  ,  have'  eo.ne  forward  .leelarin,.  that  tiie  hloo.i  ot  typhus  tever 
^  '■  ;  tree  iVom  speeitie  n,iero-or.aniMns.  Kelseh's  theory,  .hat  t  -  --e 
ovph.I-  lever  is  a  Iniero-or.'anisn,  .ha.  i>  usually  in..oeuo„s  an.  he.'on.es 
patho^^..>ie  only  ..n.ler  sp.rial  .on.li.ions.  has  alrea.ly  he.-.,  r.t.rr..l  to. 

Nature,  Persistence,  and  Mode  of  Dissemination  of  the 

Contagium.-lt    foH.AV.-   h.^Moally,  r.nn.  „nr  i-noran.-e  of  the  |M-e<MSC 
nature  of  the  n,uso  mnrhl.  that  xv.-  a.'e   uuaMe   .o  say  how  a.ul  wheiv  ,t 
i,  pro.lu.-e.i   in   the   ...Iva.ni  what   orpins  a.nl  ti.su..  are   pan.eularly 
,,iV,v...l.      For  sin.ih.r  nasons  the  .lUes.io,,  as  to  the  .na.ner  .n  wli.eh 
th..   ...lison    K'av.s   the   holy    awaits   future   solution. 

Mo<t  .awerv.Ts  of  th,-  i.res...t  .lay  an-  of  th.   opi..ion  that  th..  i-o.s.m 
is  c.ntain.Ml  .-hietlv  in  the  exhalation-  of  .!>.■   pa.i,  nts-.h.'  .■xi.itv.l  a..-, 
the  .■xhala.ions   fnm,   th,-   ski.,.  .■t..-an.l   that    i.  a.ta-'he.    ..s.-lt    .o.h,. 
,l,„t   .•ontai..e.l   i..   ti,..  M..To..n.r,...L^  a..,.o-ph.T...      Mthou.^h   ,h,- -.■.■o,,.! 
„,rt   of  this   hv,,o,h.-.i>    .alli.'s  ui.h    th..   .-.■...Its  of  our   .  NiuT......r.  the 

Ih.,  ,,ro,.oM.i,^,   sho..l,l   i;,r,h.pr.s..nthea,.epte.lwi.h   ^.vat   ............ 

The    r.->-n.    tinai...  of   Kh.T.h   ha.alli   i..  the  ros.-spols  of  '> T|;;'';'    ;'-^;;; 
,N..,n-i.n.     N.-.ifehl.    ( •n.-s.'h.uunn  ^   s.n.ntrly    snL'i:esl<   the   a.  v.sah.h.N.   tn 
£  .       0  iien,i,-s.  of  .naki...  si.nilar  exa.ninnti.M.s  of  the  typhus  lev.r  ,ash 
lil    our'  i.pr,.v..l   ha..t.Tiolo.i.-  n,..,ho,i...     That  .he  ..on.a.nmn  ,s  ..xer.  ..l 
";  ,i;^   tVees'a.M  nrh.e.  as   i..  other  intV-.ious  ,iis..ases,  se.Mns  douhtL.l  ...  the 
ca.se  of  typhus  f.'vr  ;  eertah.ly  it  has  nev.-r  h.e.i  p.ove.l. 

I,  i.  ,„-„hal.lo  that  tor  s,,,,,,-.!.,,.-  h.nMV  a...i  atUT.  as  wl!  as  .h,.-i..^. 
the  iVhrile  pe.-io.l  of  tvph...   tiv,  r  the  ..onta^i.....  ......ti.,ues  ,o  r.rro.h,,.- 

i„..lf  in   the   i,nnt...liato  surroun.iin-.^-  of  ,h,.  pati.nt.      Dnnn;^^  th.-  ..n.e 
it  „na,n,l,.e.llv  at.a.'h.-s  its..lf  to  the  .1..-.  in  the  at,no-,>he.-.     an.l  .-  vers 
onsilv  tntnsf.iTe.!  to  inanin.at..  obj.-fs  ha.,..le.i   hy,  -r  '"  '1-  ....n....i,at.. 

^:i,.hb.>rh.,o.l  oC  the  pati,.n,.  .>n  whi.-h,  „     lor   lUv,.rahle  ..ir..,.-nsta..e..s. 
it   ;ai..tnins   i,s    vi.-,.len.v   f,r  son,.,   ti......      An.on.   the-e   ,.l.,.vt-   ar.. 

cl.,thi.,g,   ..n.l..rw...r,   l,e.i-.-lo,he-,   .'urtai-.s.   .arne.-.    uphol-f.-...!   h.r...- 
'  Bra.  M'd.  J>.ur.,  Uw.,   1H^3. 


I 


irri'ii. ')(,)■. 


485 


tiiri',  unci,  ill  t":i(t,  :ill  ulijccts  svitli  a  rmitrli,  wiM.lly  -iirfacf.  Tliu  fact 
tliat  wasiirrwoiiicli,  ixdrixmi  alt('iiilaiil>,  ami  iIidm'  wlm  aif  iliai'pil 
with  tlif  (iiitv  lit'  (li>iiit'(<tiiij.''  tlic  iiitictod  articles  arc  (specially  liablo 
td  lie  attacked  \i\  \\w  disease  in  time  of  epiileiiiie  furnislics  a  strong 
proof  of   tiiis,  if  ;"iilitional    jpriNif  were   needccl. 

If  >ucii  oltjeets  are  protected  atrain>t  eoiiiact  with  air,  particularly 
air  in  motion,  the  contairimn  clinixinjr  to  them  may  maintain  its  vitality 
till'  manv  months,  or  even  lonp'r  under  e-pecialiy  favorable  cireiiin- 
«taiice~,  ami  the  disease  mav  thus  he  carrie<l  to  di~tant  localities  where 
it  was  not  prevalent  at  the  time  and  where  it  is  not  endemic,  yiicli  u 
transmission  of  the  poison  wuiild  Ihrnish  the  most  natural  etioloj,ri(r 
explanation  of  the  well-known  so-called  s|Hiiitaneoiis  epidiinics  in  pris- 
ons, on  JMiaril  shijis,  etc.,  which  formerly  afforded  -o  iav(.rite  an  arjrn- 
ment  in  support  of  the  non-sjiccific  ori;.riii  of  spotteil  fever.  These  facts 
also  rcadilv  ex|)lain  how  the  poison  may  linirer  in  apartments  iiiliabited 
liv  |)atients  if  tiic  di-iiifcciion  has  not  Ik'cii  prop<rly  attend(Kl  to,  as 
well  as  in  cab-,  raiiroad-car>,  and  other  public  conveyances.  It  should 
be  reincnilicred  that  hcaitiiy  ]icrsons  may,  without  becomintr  infi.tcd 
themselves,  carry  tile  poison  in  their  clothes  or  in  their  hair,  and  in  that 
wav  transmit  it  to  individuals  wiio  arc  not  immune.  In  the  iiitere-t 
of  the  c(>miiiiinity  tiiis  fict  should  be  borne  in  mind  by  |)hysipians, 
attendants,  cii  ij.rvmen,  friends  of  ]iatients,  and,  in  fact,  by  all  persons 
who  come  in  contact  with  tiiem  diiriuif  times  of  e|)idemic. 

riieri'  i>  a  rciiiarkal)le  reseinhlance  in  all  these  coiulitioiis  to  lliose  obser'-oil 
in  tile  acute  exantheiiiala — measles,  M'arlet  fever,  and  siiiall-|K>x.  Owiiij^  to 
tlie  i;reat  dt'velopiiieiit  of  railroad  and  iiiaritiiiie  traiis|M)rlatioii.  sp()tte<l  fever, 
like  ti  icutp  exaiitlieinaia,  has  hceu  <'arried  even  to  <lista!ices  that  would 
foriiierlv  have  l)eeii  consiilered  impossible  for  this  ilis^^ase  to  reach. 

In  liaiiiburL'  a  furrier  was  attacked  by  the  <lisca.se  ten  davs  atler  he  had 
received  a  consiirmiieut  of  furs  from  an  iiiticted  loealitv  in  I'olaud.  He  had 
not  been  absent  from  home  for  iiionths  ;  had  not  come  into  contact  with  aiiv 
one  sutferint:  fniin  the  disease;  and  more  tliaii  a  year  hail  elajised  since  the 
last  sporadic  case  of  spotted  fever  had  occurred  in  Ilamhurf:.  Fortimalelv, 
the  |)atieMt  was  iinniediateiy  isolated,  ami  he  was  the  only  one  aiuonir  his 
immediate  t'amiiv  and  attendants  who  was  infected.  The  disease  was  traced 
to  tile  iiii'ecte(l  olijecis  before  tliey  had  been  put  on  the  market,  so  that 
they  were  immediately  disinfected  and  the  further  spread  of  the  disease 
[ireveutcd. 

Transmission  by  Bodies  Dead  of  Spotted  Fever. — Even 

the  <'adavers  o|"  -[lotted  lever  patient-  may.  uinlcr  certain  conditions, 
transmit  the  disease,  althotiirh  Mnrchison  is,  no  doubt,  disposed  to 
exaiTu'cratc  tlii<  d:Mii;'er,  because  he  contracted  hi-  tirst  attack  of  s|)otted 
fever  in  the  <li-s<H'tinii;-rooin.      I  do  not    tiiink  that    the  reproduction  of 


5 


..Jf '  - 


^3-^'|i 

|| 

>.'-I-,-  '' 

486 


rvriirs  i  i:\i:n. 


^ii-^i^'V"  i) 


llic  ]>iii-u!i  ill  i\\o  <-.\A:WiT  \-  at  all  |in>lKiliii',  ami  I  Iwlicvi'  tliat  llii' 
iiitl'ctitin    take-    |ilarr    in   mv\    iniu-li   llic    -aiiic   way    ,i-    in    tlir   ra~c  nt' 

inaniiiiatr  iiiiii'.i-  (in  which  llu ntaL'iMni    Ma~  licin  (lf|i  i>it(i|.       In  ihi- 

cunnc'ctiiiM  it  -nni-  to  nir  -ii;'nilirant  that  the  (lanLi'tf  "I'  int'<'cli>'n  i~  di-- 
tiiirtlv  mnrc  marled  in  itimiiI  i-:i(1;i\  i  r-.  'rim-,  while  wc  nr\ci'  ha<l  a 
ca^c  lit'  -iiiillril    liAir   aniiinu-    the    |ili\ -i<aaii-    nf    -riNanl-    liming;     ihi' 

ciiidcinir  ill   Miialii:,  altlmnuh    innarfnu-  antii|i-i(-  wiit    niailr  in  ] I'lv 

\  fiitilatrii  rmiin-,  imr  ut'  ni\  a--i-taiit-  anil  thr  ili--i  it  ini;-ii  n  ini  attiinl- 
ant  wliii  |i(  fliirnicil  an  antnp-y  nn  a  cailavrr  a  t'rw  Imni'-  at'lcf  death 
cdiitrai  li''    the   ili-ea-e. 

The  Period  of  Greatest  Danger  of  Infection. — At    what 

])efiiid  ut' the  di-ea-i'  i-  the  daiiL't'i' '>!'  inrectiun  e;rcat(--t '.'  I 'tidcuilitedlv , 
iit  the  Keirilininir  and  at  the  liei:;ht  uf  the  I'ehiile  -taife.  l>nrilii:  tin: 
statr«'  <il  deti'|-\  1  -eeiiee,  huwcver,  the  daiip'f  nt'  ei •iitaL''i"ii  i-  tint  ineiiii- 
sidi'fal)le.  ItiirinL''  cnnvale-eeiiee,  when  the  fever  ha-  (li-a|i|)('ai'ed  ])er- 
inatieiillv,  tlicfc  i-  pruliaiily  im  fe|p|-(nhieliiin  ut'  the  ]Mii-(iii  within  tlii' 
1)im1\,  and  ennta^'iuii  dni'iiiLT  thi>  time  ueeuis  mily  liy  the  tran^tni.— imi  t<i 
|)l'edi-|i(i-cil  ])<Tsiiti>  lit'  the  |iiii-iin  that  has  liecii  |ifiidileeil  diifint:  the 
active  |iciMiid  uf  the  di-ca-e  and    hecii  dc|>i»ited  mi   -iii-fnmiditiL^  uliiects. 

It  i>  tlMic  that    I'c|-r\-  and  ecftain   ntheiv-   i-idef  the  daiiir*'''  <'t    cun- 

ta^rion  ir|-cate,-l  dnfiiiir  the  |ieiiiid  ut'  cunvale-ceiice  ;  lint  I  think  thi-  It- 
at)  crriir  that  i-  ilnc  |irul)alilv  tu  a  mi>take  in  c-timalinir  the  |h  riutl  ut' 
inenliatimi. 

I'm-  m\  ]iai't.  I  cuii-ider  ti'aiisniissiun  |)ii-silile  diiiinir  the  |ieriud  nt" 
iiieiiliatiun,  and  ali-ulnlei\  eeitaiii  diiiiny  the  initial  ^tai:e.  'I  h(>  tact 
that  dnfiiiir  thi'  lattei'  |ierind  patii  nt-  are  alilc  tu  on  alimit  ur  travel  in 
car-  ma\'  e\|ilain  inan\'  ca-e-  in  whiili  the  |)atient-  deiiv  ha\  iiitr  eumc 
in  cniitact   with  individual-  atVected  with  the  di-ea-e. 

In  this  eiimiecTinii  I  renieiulier  a  very  iiisliuclive  vam-  that  I  saw  when  a 
^tuilelil.  'This  iii'ciirreil  in  une  nf  lny  felliiw->lnilelit>.  u  Im  heeaiiie  iiit'ecleil 
while  atteiidin;.'-  aclinic  on  a  i\|ihu>  livci-  |iaiienl.  He  \\a>  nne  nt'  thni' 
stmleiits  t'riini  another  i|e|iai-|riieiit.  ulin  liad  spent  an  limir  in  a  t\|ihii>  t'ever 
iiatient's  riiniii  al  a  lime  when  the  |iatii'nt  hail  iis  \  el  im  t'evcr.  and  enin- 
plaineil  (iiilv  lit'  ^liL.'ht  L'eiieral  malaise,  depressiiin.  and  pain  in  the  laad 
and  hack  ;  hut  mine  nt'  the  ;-tuilents  had  lieeii  in  the  rnnin  after  that  time. 
(  )n  the  evoiiinLT  fnllnwinir  their  visit  the  patient  was  seized  with  a  chill,  this 
heinL'  t'iilln"-e.l  liv  the  n>iial  initial  rise  in  lemperalnrc  lliLdit  days  later 
nne  of  the  liiree  -indent.-  was  taken  with  typhus  t'ever.  It  uas  s\ih:-eiplelill\- 
a-rerlaiiied  hevninl  a  dnulil  that  he  had  nut  relunieii  In  the  hmise  atier  that 
lir-I  visil  and  had  imt  enme  in  cnnlaci  wiili  any  nilier  patient  :  in  fact,  there 
had  lint  heeii  aii\-  nther  ca.-e  'A'  spniieil  t'ever  in  the  town,  all  the  others 
haviiiLT   lieen   ciiret'nllv    isniale.l    in   the    hn-pital. 

The  <|ne-tinn  whether  ur  nut    the  d.antrer  uf  intectiuii  xaries    in    indi- 


irrrni.ncv. 


Is7 


vidiial  ]i:iti(Mits  nr  in  ccrlMin  ll>itii-  cl'  ilic  di-ca-c  i<  very  dilliciili  in 
(K'cidc.  Mv  own  cNiMricnc-c  IraiU  nir  to  lidicvr  that  it  dm-  not. 
Altlioniiii  <  ii-ic— in^Ti-  (•(,n-itlii--  a  >c\(  re  ca^i'  rncHT  daii^ci'dn-  lliait  a 
tnildcr  line,  we  uv.w  xcntni'c  l<>  remind  cvcm  tiii- e\|ierieneed  aiillidr  tiiat 
it  is  MeNcr  [Ml— ii)ie  tti  e-tiiiiate  willi  -ntlieiiiit  aeenraey  tiie  inlliK  nee  to 
l)e  attriiinte<l  to  e\teriial  'aMMinir  eirenin^tanee-. 

A-  to  the  elaiin  tii:..  tile  -eVeritv  of  a  i^ivell  ea-e  i-  directly  lirojHir- 
tional  to  tile  M'veritv  of  the  <'aM'  fiMin  wliii'h  it  i~  ilerived.  1.  i'or  iriy 
jiart,  nni-t  enter  an  olijeetion.  Tlie  inteir-ity  of  the  disease  uiidonlitedly 
d'pend-  chieHv  (.;>  llie  |Mr-onal  e lition-  ol'  the  individual  altael<e<l. 

How  and  1  V  what  elianneU  (1>«--  the  coiitaLiiMin  tind  entranee  to  the 
l)odv?  1  ai^ree  with  the  inajoritv  of  ol>-erveis  in  helievinj;-  that  in  liy 
far  tile  iii-eatest  niiniher  of  ea>es  the  |ioi-on  that  eliii;:-.  to  infected 
oi)|eets  in  the  iiinnediate  \  icinity  of  tlic  patient  is  carrie<l  tliroiijili  the 
air  and  enters  the  liodv  throiiirh  the  orjrans  of  resiiiratioii.  Entrance 
of  the  ]ioison  tiiroii^di  the  sUin  is  aUo  eoneeivahle.  The  intestinal  tnict, 
whicli  plavs  the  ino>t  prominent  rn/r  in  the  etiolojry  of'  tyjilioid  fever, 
api)ears  to  lie  of  verv  sei'ondaiy  importance  for  the  entranee  ot  the 
tv|)hiis  fever  coiitajriiitn.  A  very  few  anthnrs  ( \cttor)  still  maintain 
that  direct  contact  with  the  patient  is  necessary  for  the  transmission  uf 
the   di-ease. 

The  niiestion  that  has  often  Keen  raised  as  to  the  length  of  time 
necessary  to  l>e  ~pent  in  the  neii:hl)oi-h(M>d  of  the  |)atieiit  or  the 
iliiration  ol'the  contact  with  inanimate  carriers  necosary  to  |irudnce  the 
infection  has  a  pi n'elv  theoretic  interest.  (Ii\-eiitlie  necessary  coneeii- 
tiation  ot'  the  |ioison  and  a  fair  debtee  of  predis|Misition  on  the  |)art 
of    the     iiidi\idiial,    it    ajipear-   certain     that    a    very    short     time — -I'Ven 

a    liw  nioni'  nt^ mav  suniec   to    infect    him,  altliou;_di    it    will    lie    fiiiind 

ditliciilt     to    procure   relialilc  evidence   on   tlii-    point,   <--|)ecially   diirinj; 
an   ciiiih  iiiic. 


1  saw  uii  iiistriictive  ease  of  this  kind,  oeciirrin;:  in  ii  furniture  iiianiifac- 
turer.  who  was  (iiiite  certain  that  he  had  not  eoiiie  in  contact  witli  any  fever 
patients  nor  with  an\-  suspicious  oiiji'cts,  and  MiiiouLr  whose  employes  there 
hail  iiiit  heeii  any  case  of  spotted  fever,  lie  had,  however,  interviewed  a 
Wdrkiiian,  who  appiared  to  him  to  he  ailiiiL'.  promisiiiir  him  einployinent  after 
he  shoiilci  have  recovered  his  health,  'flic  interview  diil  not  iasl  more  than 
five  minutes,  and  was  held  in  his  ]irivate  otiice,  which  was  very  small  and 
hadlv  vcntilaled,  the  windows  lieiiiL'  cIommI.  Twd  davs  afterward  the  work- 
man was  sci/eil  with  tv|)hus  fever  and  admitted  to  the  la/aretto  at  Moahit, 
where  he  had  a  typical,  tlioiiL'li  mild,  attack  ot'tlie  clisease:  while  the  maiiu- 
faeturei'.  whom  I  >aw  while  actini'  as  a  eon>ullaiit  duriiiL'  his  illness,  con- 
tracted a  verv  x'vere  foria  <  '  the  disease  on  the  seventh  ilay  after  his  inter- 
view with   the   workman. 


m 


^g^^^ 


488 


TV  I'll  IS  I  i:\i:n. 


Mii-i  [latiriitr^  irivi'  :i  !ii-l!ir\  n!'  hiiviiii:  lii'cii  1  mi-ciI  ti>  ini'irtinn 
rciK'nIrilK   (ir  (■iiiitinuoii~U    tiira  Imi.j-  linic       I'lir    |)rri'i-c  iiioniriit  wlirii 

till'   |piii-ii||   rll'icl-  an   clltlMIlii'   inl'i    (lie    limlv    i-    111!    (liilllil     llr|Mll(l(lll     nil 

aci'iclcntal    iiidi^  iiliial    "V  rMcnial    I'Miiditiuii-. 

In  ;:'('ii(i':il  it  riia\  \»-  ~;ii(l  lliut  tlii'  ilaliLicr  nt  iiilirii.pn  iiicria-o  with 
the  tV<(|iicii(S'  ami  iliifalinii  lA'  cxiiii^iirc  aiul  willi  tlii'  loiiccuti'alidii  nf 
the  poiMin.  '\\\v  lallcr  >Iaiiil--  in  ilirccl  ratio  to  the  hiiiiiIhi' ot' patii'iit-^, 
and  ill  indirect  I'atin  In  tlic  >\/.v  and  cxciilinif  ol'  tlic  vcntiialiiiir  tiicilitii'S 
of  tlif  ward-. 

Reaction  of  the  Poison  to  Chemical  ind  Physical  Agents. 

— Tlic  |Hii~oii  a|)|«ais  to   I ii-taiitly  rcju-iMliiccd  in   the  IhhIv  of  tlie 

putii'Mt  dnrinjr  tlic  I'clirilc  |)iiiiid,  and  it  iiiii|ni-tiiinalpiy  maintains  its 
liiixlit'^t  dcj^fcc  <it"  virulence  in  hi-  iininediate  \ieinii\,  hciiii:'  intimately 
united  to  dii-t  and  ntlicr  carriers  of  that  kind.  It  doe>  not  a|i|iear  to 
Ik?  ea.«v  to  destrov  the  ]ioi-on  liv  <'hemical  mean.-.  ilic  -implcr  methods 
of  di-infeetioii  t'ornierly  ii-cd,  -ueh  as  -prayinjr  the  room  with  carliolic 
acitl  or  chlorin  water,  are  pidhalily  of  very  little  v.ihie.  'I'lie  newer  dis- 
infectants that  iiavc  leeciiily  1m  en  recommended,  snch  a-  formalin,  have 
not  as  vet  hecn  tlioroiiiihlv  ti>-tcd.  The  di-iiifii'tioii  ot'  l)c<i-,  linen,  and 
otliei'  ohjects  n-cd  alioiit  the  patient's  Ixnly  with  the  al)ovc-iiamc<l  disin- 
fci'tants  is  ipiite  iiiad(<piate. 

I'hv-ical  aircnt-,  on  tli<>  other  hand,  .aiipear  to  he  far  more  dc-trnctivc 
to  the  |Kii-oii  than  anv  chcmi<al  di-infectaiits  hiiown  at  the  prc-eiit  time. 
Hiilh  temperature- i-pccially  are  ot'  value  ill  tlii-  re-pcet.  In  Moahit, 
where  manv  experiments  with  dry  heat  wire  made,  tie  clothes  and  por- 
.«onal  etlect.s  of  the  patients  were  rendered  aliMiliitcly  sti'rile  liy  ex|M)suro 
to  a  tem|ieratiiri'  of  Idii     to  12n     ( '.  for  one  or  two  Imurs. 

Of  the  effect  of  cold,  very  little  is  known,  althoiiudi  Mildcnlirand 
believes  that  very  low  temperatures  liuve  a  di.-tiiietly  destructive 
iiiHucncc. 

It  i>,  of  course,  well  known  that  epidemics  arc  hotli  more  fre<i|Ueiit 
and  irrcater  in  extent  dining  the  winter  than  duriiijr  the  suniiiicr  ;  this 
is  due  to  the  social  conditions  existinji  durinjr  the  winter  season. 

It  would  a|i|iear  that  the  |ioi-oii  is  not  carried  a  \ery  jrn.at  distance 
thi-inif.di  the  air.  According  to  my  cxperieiiee,  it  is  much  less  easily 
trau^iiortiil  than  that  ot"  variola,  and  possilily  also  than  that  of  other 
acute  exanthemata. 

While  in  sTnall-|)ox  epidemic-  I  have  ot'tcn  seen  c.isc-  in  wliicli  the 
]>oi-oii  wa-  wafted  across  a  iiai'i'ow  -treet  a.nd  carried  to  the  inmate-^  of  a 
liou-e  on  liic  o])])o-itc  -idc,  I  have  ne\'er  -ecu  iiifeetion  carried  in  this 
wav  in    Moahit,  where   we   had   ol'tcii    to   till   one   harrack-   with    tyi)hil.s 


jiamm,:.Xii   :  1 


.1!: 


/  7,'  I.IUSI  'o.s/.w  ,■   ( 'OM)  inn  SS. 


-l.s'J 


l>:iti<  Ills,   am!    tlic   aiijniiiiiijr  uiii    with    |i;iti(iil-     litli  ri'i/    t'roni    -iirj^qiul 

injiiiic-.       It    i-^  (i\viii;r  to  lliis  (|iialitv   nf  tlu iiiiLriiiiii — that  'if  not 

hcmLT  <'a>il\'  <'arri<<l  to  a  jxriat  di^taiuc — tliat,  whiii  an  i.-olatcil  ca-c  of 
ly|ihM~  tcVtT  i-  athiiittil  to  a  ho-|>ital  l>y  iiii-takc  or  want  of  JikI^'^- 
intiit,  the  <li~('a>('  liocs  not  >|>rcail  li<'von<l  the  paticntV  iniincdiati' 
n(i;rlil>or^,  |iro\  iiliiijr  tlit  wanls  arc  lartro  and  airv.  The  rpidiriiic 
hiHoiiK^  jr''"t'i~ii  oidy  when  the  nunilxr  of  typlins  patient.^  in  tiie 
wards    increases. 

N'entilation  has  a  marked  ii.tlucnce  on  the  contairii'in,  tlie  ])rophv- 
lactic  iin|)ortaiice  of  which  cannot  l)e  too  nineh  <'inpliasi/ed.  In  large, 
wcli-ventilated  wards  that  arc  not  too  crowded  the  virulence  is  nuicli 
diininishcd,  especially  it'  the  patients  are  kept  in  the  ojx'ii  air,  or  if  the 
doors   and    windows  arc   hit    oiieii. 


I  made  some  very  instructive  iihscrvatinii>  in  this  respect  in  the  la/aretto 

at  Moahit.      Duriiiir  the  siminicr  i ihs  1   kept   mir  patients   aliiio>t  all  dav 

in  the  o|)eii  air,  wiiich  incidentally  had  a  very  ^.'ood  thera|)eutic  etlect,  ami 
in  winter  the  windows  were  kept  constiintly  o|H'n,  the  wanls  ix'iiij.'  ke|it  well 
heated,  however.  Not  a  siiifrle  physician  ami  very  tew  of  the  utteiidunt.s  were 
infected  ;  of  the  latter,  oidy  those  were  iii'ected  who,  contrarv  to  iiiv  orderfi, 
liad  liathecl  the  ])atieiits  in  the  small,  ill-ventilated  hatli-rooms,  instead  of  in 
the  spaiioiis,  well-veiitilateil  ward. 

S)  inncli  ii>r  tlu>  reneral  conditions  that  t'a\or  tiie  origin  and  spread 
of  the  disease.  'Ihe  |M)ison  has  always  Keen  tinind  most  virnleiit  when 
large  nnnd)er;  of  |)ersons  have  l)e<'n  irowded  toge*^lier  in  imprope.lv 
Ventilat(Hl  and  ill-kept  localities  under  had  hxgienic  conditions.  I'risons, 
badly  planniHl  Itarnicks,  iinis,  and  liMlging-housc.-  of  the  lowe>t  kind, 
work-lioiises,  ships,  and  defectively  liuilt  hospitals  are  the  chief  foci  of 
the  disease.  Ileuce  it  is  that  w<'  have  the  varion-  synonyms,  la/;iretto 
fever,  ship  lever,  prison  fever,  camp  fever,  etc. 


PREDISPOSING  CONDITIONS. 

PERSONAL  CONDITIONS. 

Tli(>  ])r(><lis|)o^ition  to  typhus  fever  appears  to  he  universal,  and  is 
very   strongly    devclo|H'd    in    most    individuaU. 

Immunity.  —  Very  few  appear  to  lie  entirely  immune  hv  hirth. 
The  older  authors,  iiotahly  ilildcnhrand,  hclicviKl  that  the  body  coidd 
hecome  ac<'U~tomc<l  to  the  |ioison,  and  in  thi~  wav  a  certain  gnide  of 
aiMpiired  innnunity  against  tiie  disea.-('  might  lie  dcNclopt-d.  as  among 
attendants,  phy-icians,  and  priots.  who  tVcipicntly  work  among  patients 
during  >,'vere  epidt-mies.      I    think   this   i-  very  douhtlid,  and   none  of 


I 


490 


TV  I'll  Is  I  i:vi:i:. 


tlir  iiioic  ircciii  aiillnir-.  aiiiiiiiL;  \\  li"iii  I  \i.ii,li|  cninit  ii,y-(ll,  :i|i|i(ai-^ 
til  lia\r  hail  ai!\    l'a\  iralili-  r\|M'riiiirc  in  ilii-  ri-|icrl. 

(  )ii  the  I. till  I-  liai'd,  I'lic  allaik  I'f  the  di-ia-c  (diil'ns  all  aci|niiv(l 
iiiiiiiniiil\  "11  llir  L'lval  iiiajmilv  nl' |i(i-iiii-,  la-liiiir  a  Iciiiij  liiiii  —  n-iially 
I'lir  llir  rchiaiiitli"-  "!'  lli"  iiiili\iiliiar-  liti\  In  llii~  ri-|H(l.  al-n.  t\|iliiis 
I'cvi'l-  n-rnililr-    llicanili-  lAanllicniala.  r-|iiiiall\    -rallit    li\fr,  rma-lr-. 

anil    varii.la.       Whitlnr    ihr    iIilTci'    "f    i lunily    atlrr    an     allaik    nf 

l\  iihii-  I'lM  r  i-  a-  i:i'i:il  :i-  i'  i~  in  lln -i'  ullni'  di-ca-t-  i-  a  c|nr-tiiin  n\\ 
\\\\\,-\\  iliriv  i-  a  illlViivncc  lit'  ii]iini.pn  ainnnLr  lli<'  val-inn-  aiillini'-. 
( ;ii(  — inL;ii'  ami  Muivlii-nn  i-r|"irt  ca-i-  nl'  llir  siinc  in<li\iilual  lirinu'' 
allacUdl  \nnvr  than  nmi.  <  ;rii--inu'ti  'lut-  nni  -nin  In  ciin-iili  r  thi-  ii 
\(  rv  rair  iHiiinirni  .  ami  Muivlil~nn  ari|niivil  lii-  cxiicrirnrc  trnin  his 
iiwn  la-c,  he  liavinLi  luin  atlarki'd  twice  li\    the  di^ea^i'. 

It  lia-  liriii  iv|iiiiii  d  ill, I  ihr  -anir  indi\iiliial  ha-  lurli  atlarUiil 
twirr    (Ai'll     ill    till-    Slini'    i|iidrniir. 

I    ni\-rlt',  Imwrvrr,  am    nl'  ll pininii    that    mic    attark    id'   ty|ilms 

fever  cmt'ir-  alnm^t  a-  iierteet  an  iiniiMiiiity  fur  the  remainder  ul  the 
inilividiiar-    Ii..'   a-  due-   an   atlaek    nf  any  of  the   exanthemata. 

Fii  ei)ii>e(|iienee  of  sueii  a  lieiiet",  it  lias  Imi'.'  Iiecii  the  eiistimi  rvuryvliere 
ill  the  hri:iimimr  ufan  e|iideiiiie  111  emiiliiy  alleiiilaiits  ulm  liiive  already  had 
llie  ili-eaM'.  The  wiMli.iii  nf  this  |ii-iieeiliire  i>  pi-nvid  l>y  M lirrhisiili's  ex|ieri- 
eiire  ill  the  Lemliiii  I'lx cr  lliis|iital.  lie  si\ s  that  he  never  saw  an  atteiid- 
aiil  allai'kid  iiiore  than  miee. 

Age  and  sex  a|)|ieai-  \'>  evert  ;,  very  -iiliiirdii'ate  iiiHiieiiee  nil  the 
-u-rt  iiti'i.ilitv  to  ty|ihu-  lever,  a-  i-  -Imun  whenever  the  eiit're  ]Hi|inla- 
tinii  111'  a  liie.ilitv  i-  iA|iii-ed  til  the  -.line  ehanm  1-  id'  inreetinli  niider 
identical  cxti  nial  ennilitinli-.  Nut  inenn-idel-.ilile  ditVerelice-  lia\e.  lit 
ciinr-c,  lieeii  iili-crwd.  -nine  i.r  which  are  ea.-i!\  e\|)iaiiie.l,  while  tnr 
(ithiT-   the   c\|ilanatiiin    ha-    imt   .i>    \v\    \<rv\\    tlninil. 

In  main  e|iidemic-  the  male  ]iu|iiilatiiiii  i-  nunc  generally  attackid 
than  the  t'ciiiah  ;  luit  win  ii  the  cnnditiun-  are  careriilly  exaniiiicd.  it  i- 
liiiind  thai  the  male-,  n^v  iiiix  tn  thcii'  inndc  nt'  lite  and  iiccii|iatiiiii.  are 
iiinrc  l'ni|iicntl\  and  mure  cMii-tantly  e\|H.-eil.  Imth  tn  the  |iiii-iiii  it^cll 
and  til  the  varioii-  iireili-|iii-iii:.'-  I'actiir-  ;  and  wc  accurdinely  find  that 
w  heiiiA  er  the  di-ea-i  i-  can'iei!  intn  lncalitie-  that  had  lictiire  liecii  Iree 
t'l-nin  illt'cetinn.  llie  c,a-i-  ale  at  lii--l  almn-t  e\chl-i\cly  ennlilled  tn  the 
male   |iii|iiilatiiin.  Imt  :i<  the  di-ea-e  de\elii|>-.  and    in  the  cniirM'  nt    tiiiii' 

eiadiialK'  extend-  tn  the  n-ideiit  |)nrtii f  the  eianiniinity,  tlie-i   dilli'i'- 

ciicc-  liiadiialh-  di-a|i|iear.  In  cniilitrii-  where  the  di-ea-e  i-  endemic 
and  i-  Imt  lirnii;.dil  in  Kv  ihc  ilnatin<:  |iii|iiilatinn.  it  ii.-ually  aU'ect-  l.intli 
.-exe-  ciinallv  t'rniii  the  licLiiiiiiiiiir- 


ri:i:iiisi">sis(,  <  h.mii rinxs. 


I'.il 


'I'lir  l.ol  prnnlV  ..r  ilii>  Wf  liiiil  in  Kiiirlaiiil  ;'ii'l  Irrhiinl,  llic  diL-^n'  limnrs 
•  >(  ty|iliu>  I'lM'f.  Ill  till-  l,<iiii|oii  I'l-Ncr  l|ii-|.iliil,  iliinni.'  rniirinii  \i;ii>, 
:!7.>ii  iiicii  :iii'l  -'iT'.'J  "niiicii  uiri'  ailiiiilli'il.  hiiriiiL'  lln'  Irisli  c-|iiilciiiic  n| 
1H|7  I'.Mlic-  iiiiiulii'i-  i>l'  uiinicii  «a>  rvcri  LTtMlcr  lliiiii  ilia  I  nf  ijic  imii.  .IL'.I  II 
IumI.  -  Mini  :;  I. .■;'.'>  liiiiali-,-  hriliL'  allaikcii   li_V  llir  ili.»a.-r. 

It'  ur  ciiiui'Mi-c  ihi-  uilli  llic  Malisiirs  nlitaiiinl  in  (liill.-lal  in  rni.-^ia. 
wliiTc  ly|iliiis  I'lMT  i~  riMlimir  'inl\  in  a  iiniilcil  -cii-c,  aii'l  i>  ii-ijall\  lii'iini;lil 

in  IV n('iu'lil>"rin_'  cMiinii-ir.-,  uc  tiinl   llial.  .Iuiiii_'  tiic  ycai>  tVoiii   l^>l  lu 

Ix^.'),  aniniiL'-   ii   tula!  of  :;'.tL'."<    indiviihials   alun  k.       \\wn-  wivv   L".in.p   malrs 
ami    jlij:!   t'cinalo. 

Till' slalislics  llial  I  iililain.MJ  in  Mualiil  ^ll•il.inL'ly  illn^'tratc  x\  iial  lia|.|i.n.s 
wlifii  ilic  ilisiMx'  is  not  ilistinclly  cnilcniii-  ami  ulicii  -tfinL't'iit  liyiritiiic  |in- 
caulions  arj.-  laki'n  to  |in'vcnt  the  lloalinL'  |io|iiilation  from  iiifcctinL'  the 
InTMiancnl  i-.'-iilnit.-.  Diirinir  iIh'  year-  I  ■-T'*  ami  |s7!l«f  trcatid  l.y  far 
tlic  LrrraliT  nuinlitr  nt'  all  ra>r.-  of  i\  plius  i\\rv  that  occiirrfil  in  iHrlin.  a 
total  of  .■)■_' (I  ;  ol'tlicsi-.   t'HH  \\,\f  inalo  ami  only  :;•_'  ffiiiali'S. 

Unthcntlur  liaml.  we  have  an  intcrolinL'  oinniniiiicatioii  from  l'a>saufr, 
wliirli  |irovcs  that  wlicii  tlif  sexes  arc  (M|iially  cximisciI  to  infection,  llii'y  are 
ei|iiallv  Mi>ce|itilplc.  !Ie  tells  of  a  wc.Min.'  |.arlv  tliat  foiiml  a  lyiilms 
|iatient  in  llie  lioii>e  wlierc  tlii'  wciMiiiL'  was  licM.  and  that  folloueil  him  to 
the  L'rave  a  few  days  later.  Of  the  niemUers  of  the  party,  lit  were  attacked 
— ."<  of  them  women. 

I  ni\>clf  have  oliserved  similar  cases.  I  renieniliiT.  dlirinL'  the 
Herlin  epidemic,  in  one  of  the  meaner  lodidiiL'dionseS  the  proprietor,  his 
wife,  two  hiirinaics,  and  a  |«)rlcr  wtTf  attacked  at  the  very  out.set  of  the 
epidemic. 


As  to  the  (pic-tioli  uf  the  iliHllellce  of  agC,   We  liillst   licit    place  Iilllcll 

feliaiK-e  uii  iiieic  iiumliei's.  liut  iiiii-t  take  into  coii-idei-atioii  not  only 
the  variations  in  physical  ciinditinii  iiieideiit  to  aire  itxlf,  Imt  alxi  llic 
(lin'erellces  ill  social  condition,  liindc  ot'  life,  occiipatiiHi,  etc..  peculiar  to 
the  ditliTeiit  period-  of  life.  If  we  examine  the  reports  lia-ed  on  lar^ro 
ntinilicr-  <A'  iiaticiil-  in  cxteii-ive  cpideiiiie-,  or  the  stati-tics  id'  lar.L'c 
lio-pitals  in  ty  piin-  li'vcr  rceions,  we  tind  that  the  di-ea~e  i>  not  marly 
.so  iiiiicii  conliiuil  to  a  certain  |)eriiid  of  life  a-  arc  the  other  acute  inicc- 
tioii-  di>ca-c>,  c-iiccially  typhoid  fever.  I-"\cr\  ]icriod  <,\'  lit!'  will  lie 
found  re|irescnted  anionic  tlic  adults,  iiicliidin^  individuals  over  tifty 
years  ol'  a^c,  in  whom,  as  is  well  known,  the  predi-pn~itioii  to  typlioi<l 
fever  is  diiiiini-licd.  In  fact,  th(  stati-tic>  in  any  lartrc  epideinjc  of 
coiisideraMc  duration  -1;  iw  that  the  |)ercent,iL'-c  i-f  imiividuals  attacke<l 
in  the  later  dcca<lc- of  life  is  ipiite  a>  irnat,  or  even  ereat.r.  than  tlie 
jureciitajjc  of  all  patients  anions:  the  inhaliitants. 

Childnii  arc  ipiitc  as  lialile  to  the  di-e:i-c  as  per^m-^  of  advanced 
ajjre,  altliouuh  ohlcr  children  ajipear  to  lie  iiioiv  siisce|itililc  than  youiiLTer 
oiie<.  Infants  at  the  lireast  are  the  least  ,!ispo-ed.  Aiiioiil^  children, 
tho-e  lietweeii  the  a<res  of  live  and  liiiirtccn  appear  to  lie  tlie  ones 
liKist   eoniiuonlv  attar  ked.      i''roni   the  first    to  the  tiftli    vc;.--,  ;u-t   as  in 


I"'.' 


I?  a 


I  ^liii 


I 


f,           • 

i  ■ 

I 

■ii 

1 

IDL'  7  177//  s  ii:\i:i:. 

Iviilii.iil  I'l  \  ir,  till'  -ii-ci  |ililiilil\  i-  (liiiiini-lii  i|,  :i1iImiI|;^Ii  il  i-  ill-liinl  ly 
^ivalii  lli.in  in  -mkliii'^  iiil;iiil-.  'I'lic  di  ;:i(i'  i.l'  li:il,ilil\  i.l'  cliildi'iii  i- 
-iirri  «liiii  an  i|iiiliiiiir  linak-  miu  in  a  |ipc:,lil\  wlnii-  llir  ili-ia-r  lia- 
ra::ri|  li.r  -oiik  time  aiiioiii:  tin-  a>liill  |>i>|iiilatii>ii,  a  l:'(""I  inaii\  cif  w  lioiii 
air  iiinnniii'.  I  iidrr  -inli  rii-iiiin-tain c-  ilic  niolliiilily  aiimnj^  cliililicti, 
wliicli  ii-iiall\  raiiL;(~  licluciii  1 '_'  ainl  |ti  pir  rciil.,  Mia\  iiicrra-c 
<li(ii'iniiii-l\  ,  a-  i-  -InixMi  hyllir  l»ii|-|ial  i|ii(li  iiiic  nt"  I  Mill  and  1SI17. 
In  llii-  I  |iidtiiiii-  r.ili-c  liiimd  iliai  111!  |M  r  (cni.  iil'  llin-r  atlaikiil  ucri' 
cliildivn. 

I  lir  tiicl  that  aniunL'  iidull-  llic  jirinic  "f  litr  and  ini>«t  pnidnrtivr 
I'l  riiid  luini-li  ii!in-nall\  lari;c  nnnilirr-  nt'  ca-c-  i-  i-cadilv  (Aiilaiiicil  liy 
i\ti  rnal  i-nndiiiMn-.  It  i-  dnrin;^  tlii-  |ii  rind  liiat  a  man  i-  iimi-I  artivc 
in  llif  -truu'-dc  \'<<r  i\i-ti  ikc,  ami  i~  tlicn,  nmir  tliaii  at  an\  ntlirr  lime, 
<\]Hi-.d.  liiiili  to  llic  dani;!'!'  nf  inl'ntinn  and  tn  |ii-i<li-|Mi-inL'-  lactiit^. 

I'.. I-  a  funlifi-  cliiciilatinn  nt'  llic  .-alijiM-l  llic  tnllduiiiLr  lalilfs  arc  addcil. 
Tin-  tir.-l  taliii  >li(ius  the  ili>trilnitiiMi  a.'*  \<>  atrf  nf  llii-  44(1  luitii-nt.-  ailiiiilli-cl 
ti)  till-  la/.aritl(p  in  .Mualiil   in  llic   year  l^T!*: 

\.j,  t'atlctit'i  iiilliiilli-.|. 

UimIit  In  ,       :; 

In  1,.  ■_'(! 40 

•jn  i.i  ;:o IKL' 

.■■,(1  t-  |n  l'''> 

In  t,,  .'.n  <>H 

:,{>  I,,  i;n riS 

i:ii  I.,  Tn  8 

7n  t"  ^n  1 

44(> 

If  \vf  ('(iiniiiiri'  tliis  talilc  witli  tliiit  nf  an  ciinnl  niiinlior  nf  tyiiiioid  fever 
ca.-e-  siniilari\  arraniri'd  aeeordinL'  tn  Hire,  we  >ee  at  niiee  that  in  ty|ilnis  llie 
latter  [icriiids  nt'  iil'e  are  inure  >tr(iiiLdy  rc|ireseiite(l  :  almost  oiie-tliird  nf  the 
patient.-  were  nvcr  I'nrtv  years  ni'  aL'e.  and  41  nf  440  patients  were  lietwecii 
tiftv  anil  >c\enty. 

A  similar  residt  is  shown  in  the  fnllnwin;.'  table  from  the  (inttstat 
statistics  : 

\;;c.  Tatiiiit^  nilniittod, 

fn.l.r  i;,  K'. 

1".  to  »n ;!0ii4 

In  1,.  i;n      i.W 

(Iv.  r      i.n  .    .  «!' 

N.it  a-.rrl:,i.ir,l 72 

Miirehisnn's  statistics  of  I!  t')()  cases  treated  in  the  I^/ondnn  Fever 
Ilnspital  pns>e>s  an  eipially  stnmir  interest  and  are  particularly  instructive 
liecaiise  thev  deal  with  a  cuiintrv  where  tvplius  fever  is  endemic'. 


I'IHI'Isi'osi.m;  cnMniinss. 


VX\ 


Ailc 

I..MI  II  HI. I-  r  iillu.  kk<l 

1'.  rii'Md.;!- 

L'naT  .-, 

,      .                              IT 

II  M 

■'»  t' 

III 

Ih.i 

5.  L".l 

10  t. 

1    . 

.lii;t 

KH7 

iri  to 

•.1> 

.Mi; 

!■■.  T'l 

•M  to 

*2'i 

I'l. 

1 1  ■■'■■d 

•ih  u 

:iii 

.11.; 

'.1  '.I'J 

no  1. 

,    .          .>-■• 

u.;t» 

:t."i  (• 

I'l 

.   .        :.'7t» 

7.81 

40  t. 

1  . 

•_".|'J 

H   11 

4r>  t. 

:,ii 

■.'  1  -J 

If.  i'> 

6()t. 

.'i.'i 

I.MI 

1  u 

55  t. 

i.ii 

IIHI 

L'  '^'.l 

till  !• 

1  'i               .    .    . 

•^'^ 

1'  .".I 

Il't  t' 

'■1              ... 

•!-' 

1    Jl 

Til  t. 

Jl 

II  ii'.l 

T'l  1' 

HII 

i; 

U.  17 

U VIM' Ml 

o 

o.cw 

;4.m; 


Till'    prn|.iirtiim   of  rliiMri'ii    uttackfil    i.-     'lii-lnil.Ml    1>\    llir    rollmviiiLr 
res  i-oliiTl(.|  liv  (  Ir.i/.iT  iiM.I  IaOhtI  ilurini:  ihf  r.rf.~l:iii  r|.i.|iiiiir  nf  \s[\'.\. 

Of  :i   Ii.imI   lit"   l"*?:;   tvpliii-   fiMi-    pill     Ml-.    271.   oi-    14..>,    |..r  iviil.,   uirc 

chiliiri'ii.  iliviiifil   iiccunliii^'   lo  ;igi'  m.-*   Inliow.-!  : 


flirii 


HI..  I 

1  1-  .'. 

.-,  t..  Ill 

111   tn  I.') 


NuinlK-r. 
O 


l.V.l 

i;7i 


The  tiiMp  «li(i\vs  ii  iiiarki'il  rise  in  the  |irii|n>rtiiin  witli  ■iiicrcii.^iiiL'  iiire. 
and  a  iiiilaritv  in  llif  prii|iiirtioii  sliuwn  liy  llio  variniis  airoiit'  rliilillii""i  In 
thai  ill  ivpliiiiil  It'M'i- — a  -iiiiiiarily  tliat  ili.-^appt'ars  in  the  case  ut'  ailnll.-^. 

Atrain.  siirkliiii:  iiit'anl>  >linu  a  viTv  siii'lit  ili.-|Kisiliiin.  a.-  ilu  also  I'liilijrcn 
iiniliT  tivf  vcai>  lit'  a^'i'.  I'rnin  tliis  pfrioil  the  lialiilily  inrrtaM>  willi  facli 
yi-ar  of  lit'i'. 

('tilain  jiliv-iiiliio-ir  (•iiiiiiitiiin--  animio'  wuiii'ii.  -inli  a«  pregrnancy, 
tlic  puerperium,  ami  lactation,  ilo  not  appear  tu  have  any  |)arti(ii- 
lar  inthifiici'  mi  tlic  lialiilily  to  ty|iliii-  fcvri-.  imr  iln  tiny  rnntiT  any 
iniiiuiiiitN  a^'aiii-t  tlir  lli^-(•as('.  'I'liis  i-  an  int(  ri'-tin;.''  puint  in  tlir  ilit- 
fcnntial  iliaLnm-i-  t'nmi  tvplioid  f'cNcr.  airaiii-^t  wliicli  tlic-c  conilitiuns 
appear  tu  atl'nnl  a  reiiain  iinitcitinn.  'i'lic  intliicncc  "f  tlic  ili.-ra>i'  nn 
till'    fetus    lia-    111)1    a-    vet    liceli    deterinineil. 

General  Conditions. —  I'lie  general  bodily  health  ami  tlio 
individual  ami  social  conditions  of  life  on  wliieh  it  ilppeml- jilay 
an  important  rn/<-  in  the  etinlofxy.  Opinions  on  this  [Miint  have  not  lieen 
moililicl  to  anv  exient   hy  tlie  eN|ierienee-  ot'  later  years. 

It  is  a  matter  oi  general  exjierienee  that  tiie  liahility  to  typhus  fevor, 


J, , 


I'M 


/  1  /•///  V   /  /  1 7  /: 


'  v'i-  .-..J' 


r  '^. 


iti  ii-.  ir  -.1  \M  II  111. III.'  'I  iimI  v\  i'I'  --|h.  mI.  I-  nil  rni-cl  |.\  anMliiiiL'  lliat 
(•\li:ni-l-  ill.  iiiiliv  hlii.il  ili'l  1m\m|--  111-  Im..|||\  .iikI  III.  III. iI  I. .111.  \\:illl 
.111.1  |»'\.ii\,  Ihiiil;.  i-  iiii.l  \\..n\.  .iiiil  "llhi  .i.  pr. --1IIU'  .  in  uru-l.iiiccs 
ll;i\>'    :iU\.i\-    I" '11    ill.-    iii"-l     |>..v\.'l  lul     illii-    "I    ill'     .li-.  ;i-.-. 

Siicli  .  ..ii.lili'iii-,  "I  ."111-.,  in. 111. I.  iiiili\  L'l.  iii''  li\iiiL:-  aii.l  .■!'.-.■ 
(■I'lW.liii'j-  ill  lillliv  all. I  ill-\  '  lilil.il.  .1  li'.il-.-,  -ul'j.  '  I-  llial  lia\.  ali-.a.jv 
I"  .  II  -iillii  iciilh  .Ii-' 11--1 .1.  \\  .  Ii,i\ '  -.  .  11  u  lial  an  iiii|K.iiaiii  pari  liny 
|il,i\  ill  iiiiiiil.iiiiinj-  an. I  aiiL'Hi.  ill  iiii:  lli.'  \  inil.ii.'.-  ..I'  lli.'  .  "iil.i'jimii. 
>ii'  li  iiiij'i\  ..raM'  .  "ii'lili.'ii-  ir.  iialiiialK  iii'.-l  niailv.<l  in  liiii'-  ..I 
irciM  i-ii  'I'  -I  lull'. II  .III. I  '...ii'iiiii'  'I'  |ir. --i'.n.  .luiiiij  uar  .iml  "ill.  r  ;_'ii.il 
iii"\  'hi'  111  -     iiii'.iil:    I  li.     |."|iiil.ili"ii. 

ill  1  III-  II  -|i'  .  I   1  \  |iliii-   I.  \ '  r  :i'^ain   |ii'  -.  nl  -  .i   in.      ..  .1  .lill.  i.  n.'.'  Ir.  mi 

t\  I'li'ii.l  I'  \ '  r.  w  lih  li  1-  |.r I.,    illa.k  \  "Iihl;  I  \  i-'.r. 'ii-  iii.li\  i.ln.al-, 

ami  li.i-  '■.  .iii|.aiali\ .  I\  In  1 1.  .lii .  .  1  '  "iiii.  .  I  i..n  .v  ,1  li  "\  '  i.i. '«  .liii:;,  iii-iit- 
li'i' 111   \ '111  il.ii  i'lii.  .111.1   |i"lliin.in  ..t    ill.    .ilni"-|ilii  ii  . 

\  \\  w  in\ .  -li::- il'.i-.  . -|i.  .iilK  in  I 'ranr..  Iia\  .  .  \|>r' --' '  I  1 1"  .•|.iiii"ii 
llial  ill.'  'li-.'a-i-  wa-  ii"l  .'n'  -..  inii.'li  t.'  lli.'  in.  nlil  ami  |ili\ -i'-.il 
.■\  haii-i  I  '11  iii'lii''.'!  !.\  |..i\'il\  an. I  ;:.'n.  ral  iiii-.  r\  a-  I"  I  li.'  in.  \  ilal.l.' 
liia--iiiL;'  !"'j'lliii'  ..I  l.ir'j.  iininli.  r-  in  -mall.  li.a.lN  \.iililal..l  li.'ii-c-. 
ami    ill''    .■.111-.  .|n.  Ill     in.ii  .i-.  .1    .laii'j.  r    "I'lin.-I    inl'ili"!!. 

\  i^laii.''  at  till'  .'.in. Iiii. .11-  ..l'  lli.'  L.tt.  r  'la--.-  will.  Ii'.u.-s.r,  -iilli.'.' 
t"    1' riin-    ilii-    "|.iiii.'ii.       Alih'.ii'jli    ilii  \    li\.'aini.l    l..ilrr   -iiri"iiii.limj- 

aii'l    in    in..r.'   .iriliilU    \iiiiilal..l    li'.n-. -,  il    i-  jiiiiml    lliat    a; irllii'in 

'.\'.iv\' rli"ii  ami  .  \li.in-li"ii  :i.l  a-  .li-liii.l  pn  .|i-|..i-iiii;  fa.-l"!-.  I'liy- 
-ii'i.in-.  atli'ii'lant-,  "lli.ial-.  ami  .■l''r'_'-\  in.-ii  ar.'  partinilarly  likely  t.. 
a.'.|iiiiv  ill.'  .ii'.a-i'  l.\  .■"iil.i.-l  uitli  pali.  Ill-  w  li.ii  lli.'y  an  w.ak.n..!  \<\ 
l'.ii'j-.'"nliiiii.  .1  la  I. Ml--  .liirlni'-  lli.'  li.  i^ilil  "I"  .in  .pi'liini''.  llni  r  \  ilal  l'"rcc-. 
Ik  ilii;   .'\liall-l' 'I   li\    .\.'--i\i     U'.lk.    w.riA.   :in.l    I. .--.it'   -li'i  p. 

('.I-'-  tlial  I'lirni-li  a  -IrikiiiL,''  pri."!'  "f  l  hi.-  ,-lal.  iiu'iil  can  li. 'r.iiiii.l  in 
aliii"-l  all  ill.'  .'pi'l'iiii''-,  I  n'''all  ilif  .  a-c  "fa  y.iiML'  plix.M'iMii,  in  lu.^ 
ihirU ->.''''iii'l  \iar.  "T  p'.^Mrliil  l.iiil'l  aii'l  in  pi'ini''  .'.ni'lili'iii.  w  li..  umki-'l 
lliniiiL'li  a  -.'V.i'.'  .'pi'l.iiii.'  "t'  iNpliii-  li'Mr  la^liiiL'  liir.'.-  iii"iilli>.  iluriii:: 
uhii'li  liiii.'  li.-  >p.iil  aliii.'sl  all  .la\  ami  a  l"""I  p:irl  "I'  lli.-  iii'jlil  in  ill-\i'h- 
lilali'.l  wanl^  lillcl  willi  lyplni-  pali.ail- :  l.iil.  ih'MTiIi.  1.  ^-.  li.' .li'i  i.'.I  ..in- 
Ir.'i'l  ih.'  .li-.a.-.'.  S.'iiir  tiiii.'  ial.r.  atl.r  li.'  Iia.l  l'.'''.ni'  inmli  utakiiu''! 
I,\  '.  I'laiii  ili'pi'.'—iii'.'  .'\p.'ri.ii''.'>.  l"->  "I'  -l.i'p.  Mii'l  ii.'i'\"ii-  .l\>p.p>ia.  Ii.- 
Ii'''al'''l  "iilv  a  Uw  pali'iil.-  in  u.-ll-k.  pi  li'iii-'-  in  a  lari'i'  ''il\.  i''.iilr.'i''U''l  ili.' 
.li-.a-c  uiliiin  I""  «.'  k-.  aii'l  ua-  lirmij-lil   l"  iIm-  mi'j.'  "T  iIi.'  L'rav.'. 

( '.'1-.'- "t'  llii-  kill'!  ilhi-tral.'  I.'inp'.rar\  \ariati"ii-  in  llii'  lial'ilily  nt'  llio 
«aiii.'  iii'livi'lual.  an. I  iii.'l  n.  -Imu  iliat  ilic  lial.ilily  m  lli.'  .lis.'a'-.'  may  .-u.l- 
'l.'iiK    iii'.'iiiii.-  vrv  'jnal   ini.l.r  ''crlaiii  .'"ii'lil  i"n.<. 

'  )ii  til.'  "tli.r  liaii'l.  -' t'a.'t-  can  I"'  .iti'il    t..  -Ii..\v  that    tlm  -ii-coj)- 

tiliilitv  til  tlu'   ili-i'a-c    i-   (iiiuiiii~lii'.l  wlicii    tlii'    iiMJiviilual    i^    in  pcrtirt 


/•/.7  /i/n/'"s/\<,    /  o\/.//V'/\  V  Hi.", 

(•i>rii|iii.iii,  iililiuiijli  ii'il  ill  ilii'  Niiiif  ilcirrir  a-  it  i-  iiicir  i-mI  Ia  i|.|i|(-^- 
iiii:  ImmIiIv  (■■iiicliiiMii-, 

III  II:iMiluirL'  I  Iki\  1-  t'ni|iiiiitlv  -ii-ii  |iMticiits  wliM  Ii.pI  ri.iilr:i(l<'(|  lln' 
■  li-<:iM-  ..iilfiiui-  llic  cii\ ,  ail. I  wild,  luliiri'  rMihiiiL'  tn  llii-  Iim-|iiI:i1,  hail  .s|iciit. 
Iii>iir»  ami  cmii  <I:i\-  in  l'.c|_'iirj>  -iiu.ili'l  in  iiaii-.tw  -iri'tl-.  \Mlli<nit  Iraii-- 
iiiiuiiiL.'  till'  'li~i'a^i'  III  am   nl    lln'  iiali\r  iiilialiilaiil>.       I'Ik'   hiiU   i  \{ilaiiMliiiii 

fur   llii^    lliai     I    I  an    -/iv     i-    llial    cmh    ilir    | -i  r  |iiii|ilr  in   IhiiHlMirL'  c  :irii 

i'uiii|iarali\rl\   j i  u:i.    -.anil  an-,  ar ilin.-lv.  lairlv    uill  lii|,  -■■  llial  lliiir 

liiiiiii-  ari'  ■.'rnrrall\    in  ■juimI  I'ntiilil  hhi. 

jl   III  III   lianlK    1"    -:iiil   tlial    CXhaUStttlJf    diSCUSt'S    lia\c  llir  -: • 

itl'iit  a-  \\lial  tlir  Kniiili  rail  /''  iiii<:rr  i,/,ii.^i"/":/i'jii'  .  Aliinlii:  ciiiiva- 
li-.-iiit-  |!  'hi  iitlifi'  ai'iiti'  int'i'iliiiii-  ili-ia-r-  llicrc'  i-  iiMi|Ui-liiiiial)lv  a 
Lrnati-r    .|i-|'M-iii..n    tu    contrail     lln     ili-ia-r    ain!    ri'|iriHliii(     lln     innlrrin 

tllnrlii.  Ill      l|ii-|iilll-      ullilT      till       l\|illll-      [laliilll-     a  IT     lint      -lltlirirlll  l\ 

i-nlatnl,  |iatirlil-  riiii\  ali-riti'j-  IVmim  ntlnr  ili-ra-c-  a  f  t'lunul  In  !"■ 
|iartiiMilarlv  lialili     in    ilii>   ili-ri-r. 

Chronic  or  Acute  Diseases.  -  In  ilir  -amc  way.  a  -till  r\i-tiii;r 

cliriiiiii'   111'    -iiliariilr   I ililimi  tlial   lia-  liil  In  a  inaikiii    ili-tiiiliaiirc   nl' 

llir  niilriliiiii  will  iiii  ria-i'  ilir  lialiilit\  in  iln  .li-n-r.  I  tnlixiiliial-  -iil- 
tiTiiiir  Irniii  rlimnir  nr  -iilianitf  ^la-lfn-iiitr-l  iiial  calarrli  ainl  iirr\'(iii-. 
(I\ -|ii|)-ia  a|i|ii'ar  In  lir  pari  iiiilarly  -ii-i'  |iiililr.     I'a  |ii  riiiinil  |ili\ -iriaii^ 

tell     II-     Iin\\  .    illiriM;^     Lr''''al     C'|  lii  Irlll  ic-,    i  I  H  li  \  ii  ll  la  I-    \\  lin     lljltn     thai      time 

apiirarril  tn  III- cnniiiarativrK  ininiiiin'.  niav  lir  altai'knl  it'  thrv  licininc 
rcihiri'il  li\-  ili^ri-ti\i'  ili-tiirlpaiii-r~  ami  arr  then  f\|in-ci|  In  tlir  iiilirlinn. 
I'alirtit-  -iitVcriiiir  tVotii  rlirnnjc  mr\nii-  di-ra-i-,  i -|Mriallv  \\  Inn  thcv 
arc  amiiiir  or  cinaciatcil.  al-n  aiipcai'  In  he  \rrv  ra-ilv  ititritcil. 

<  )t'  the  iiilliirtiiT  nt'  I'i  •riilatiifv  ami  riiial  ili-ia-r-,  iinthinii'  a|>j>('ar-; 
In    III'    kiinun,    iinr    lia\r    1    aiiv    riTiahlr    nli-rf\  alinii-     In    utli  f    in    tlii~ 

r(-|MrI. 

The  fi'latinii  lit"  t\'|iliii-  tiAir  In  rhfiiiiii-  |inlinnnar\  ili-ca-c.  r<|>rriallv 

III   tlllirfrllln-i-,   ha-   LI'lM'tl    ri-l-   In   -nnir  ililVrlTin  r-   'A'   n|)inin|l.         1    caiimil 

iiinlir-taini  Imw  ^niiir  nt'  ihr  [irniiiimnl  nlil.r  |ili\-iiian-.  -iich  a- 
ilililriilirainl.  ran  -prak  nt'  the  rrlativc  imi.iiinitv  nt'  -urii  |iali('nN.  ami 
I  iiiu-t  aLTi'rr  with  Miirrlii-nii  in  taking'-  the  n|i|in-iti'  -taml.  Ainntiu  iiiv 
paliniN  I  had  a  lai'L^r  niiinlirr  wlm-r  apin-  wrrr  imt  rlltinK'  -miml  • 
■■iii'l  it'  it  i-  ailmitlril  that  liilirrrnln-i^  nnt  int'rcipicnth  minpliraK-  or 
ti.llnw-  typhii-  t'rvrr,  it  ranimt  wrii  lir  ilriiiril  tliat  at  Ira-t  a  lar;:!'  pni- 
pnrtinii  ,,f  thr-r  patiriit-  liail  a  latmi  tnlnfriiln-i-  at  the  tiiiif^  tiicy  were 
int^i'ti'd  with  tvphn-. 

♦  'lirmiii'  iiitii\icatic)n~,  -itch  a-  Irad-pni-onitiL'',  ami  paitimlarlv  the 
al)ii-c  nt"  alroliiil,  act  a-  di-tiiict  ]in'<!i-po-iii<j[-  niitnr-^. 

I  h(     ctl'oct  of  the    ixii-oii  ut'  lvi)liii<  tcvcr  nn    iiatinits  >Mtl'criii"-   from 


v.m 


71/7/r.v  ii:vi:i:. 


(itliiT  acute  iiit'rciiiiii-  ili-ca-c,  c-iMciallv  diiriiii.'  lln'  trlirilc  ~ta<^c,  lia^  not 
a>    \  rt    liccii   <li-cii»c<l    ill    tile    lil(  ratiirc. 

in  ivirani  t<i  variola  ami  tvphmd  tivrr,  1  think  I  have  adihicod 
^trontr  |in",t-.  thai  they  ollrr  a  niaikcd  rc.-i-tancc  to  the  ciitrancc  of  the 
pTiii-  of  otlii-r  ai'iilc  iiitrclioii-  di>ea>(-.at  l.a-t  chiriiii;-  the  fclirilc -tairc. 
and  that  thi-  iiiiinnnilv  onlv  diinini-hc-  with  the  Kcu'inniiiLr  of  dcfcr- 
\('-cinrc  and  d(ji>  imi  di-aiijicar  until  the  fever  has  eiitiielv  siihsiih'd. 
r.iit  We  know  iiotliiiii.'-  ot'  tile  liehaxior  ot'  t\]ihii-  fexcr  in  tlii-  roiieet. 
except  in  coiMK-elioii  with  I'ceiiiTciit  fever.  Patient-  >iitf(  riiiL''  from  the 
latter  di^ea-e  are,  aieordiiiM-  tn  my  nli-ervation,  a-  well  a-  a<'cordiiii'-  to 
other  aiiihor-,  \(  ry  -ii-ceiuilile  even  duriiii;  the    fluile  .-tauc 


m 


I  >aw  an  iiiMnietive  ca>e  i.f  tlii>  kind  ciiiriiiL'-  I  lie  e|.iileiiiic  of  ISTHin 
the  lazarello  at  Mnaliit.  It  «a-  ihal  nt'a  voiiiil:-  inali.  Iwciitv -three  vcars  of 
a_c,  ill  \Wio.~e  lilipo.j  ihe  >|iirilla  liiei  lieeii  Inuiid  en  ihe  la.-l  dav  of  lii<'  lliird 
rela|iM'.      (  )ii  iIh'   full. luiiiLT  (lav  iLr  palieiil  had  a  severe  I'liill   and    lii>  teia- 

|)eraliire   hei^an    \ti   ri>e  :   the  tevei linued    liiLrh.  and  on  ihe  t'oiirth  dav  a 

charaeiei'i<lie  ami  \ery  ahmidanl  t\|iliii>  le\ir  ra-li  made  il>  a|i|iearance. 
'Ihe  allaek  wa.-  mild  and  ver\  -linri.  ihe  fever  haviiiL'  eiilirelv  di.-a|i])eare(i 
"i\    the   eleventh   da\-    (>ee    V'vi.    57'. 


cat^       ~^' 


Wk 


Needle--  \i>  -av,  cx|ierieiice-  -Hell  a-  the-e  do  not  iii-lif'\'  -iinilar 
arLinnieiit-    in    rcLial'd    to   oiher    iiil'eeiioii-   di-ea-r-. 

Occupation  and  social  conditions  i-m  iiillnence  the  liahililv  to 
typliii-  lexer  only  in  -o  far  a-  they  deierndne  the  [.liw-ieal  |iredi^|io-iiii.' 
factor-  that  iiaxe  lieeii  referred  t(j.  or  a-  lhe\  iiivoKe  an  iimi-ii  il 
(■\|)o-iire  to  the  infeeii(.n.  I'miIi  llie-e  eiinditi(iii-  are  pre-ent  in  the 
])oorer  ela— (■-.  .Viihoii;'  the  hitter  ela--e-  I  he  (|lle-tion  id'  ('\|io-iire  i>, 
of  eoiir.-e.  more  inijMirlant  than  eoii-lilnlional  condition-,  which  are 
iinfavoralile   onlv   a-   the    le-iill    ot'  aeeideiil    or  iiceii]iation. 

Some  l-"aiiili-li  anlh  ir-  claim  tiir  -pecial  oci  ii|ialiMii-  a  certain  de|_rrce 
of  ]>rotection  as.'^iin-i  ty|(liii-.  They  nicniien  in  tin-  re-|i('ct  tanners. 
Workers  in  fat.  candleinakcrs.  and  liiitcher-.  In  ;itti-ilintiiiir  their  rela- 
tive iminnnity  to  the  tact  that  they  are  more  or  Ic-s  eonstantiv  li.uidlini.f 
putrid  material.  ( irie—ine-er  niiconscioii-ly  incline-  tnward  liic  mia-matic 
theorv  of  tvphn-  lever,  which  he  has  himself  el-ew  hi  re  refilled. 

I'or  mv  jiart  I  have  -ecu  a-  ni.aiiv  cases  of  the  di-easc  .■mionix 
linteher-  a-  ann.n;.''  ntlier  workmen.  It  i-  true  that  diiriiii.''  oiir  epidemic 
the  individuals  lieloiii.riinr  lo  this  trade  were  nio-t  of  them  vairaiionds. 
I»iit  even  if  it  slioii' 1  lie  found  that  liiilchers  .ire  le-s  lialile  than  other 
workincn,  a  fact  which,  as  I  liav(>  -aid,  I  do  not  eon-ider  proved, 
the   ino-t    natural    exjilanation    is   that    tliev   are    iiiKpiestionalilv    lietter 

llollri-l,ed. 


y7:/-7'/.v/'o.s7.\v,    < oMUTInXS. 


4 'J  7 


SEASON   AND   T'^TEOROLOGIC   CONDITIONS. 

Aiiinii;.'-  ir<'iifnil  i'ti"!"j;i<'  tliclnrs  the  m.';im)m  :ii!i1  nift(tirolo;.'ic  coiidi- 
tioiis  arc  to  l)c  iiiciitioiicil.  'I'luy  ixcrt  very  little  intluciicf  uii  ivjiliu-. 
t't'Vcr,  wliicli,  tlicrct'ori',  dillvrs  in  tlii-  ic.~|)(<i  trmii  otiiir  (li.-t'a.»i'>.  In 
litct,  it  wdiild  a|)|)car  that  tlic  ilfV(l(i|piiiiiit  and  invasion  ot'  tlic  inciting 
cauM'  arc  in  no  wi-r  niiiditit'<l  l)_v  >n('li  external  eunditicins. 

It  lia>  iieen  nii-erved,  liciw f\cr,  tliat  the  di>ea>e  i»  more  jprcvalent 
during   the  culder   reason,   nm-t    ni'  the  e|iideiiiie>    havinir   roaehid   their 

heiirht    in   the  early  r th-   ><{'  the   ;    ar, — tliat  i^,  in   the  latter  halt'  of 

the  winter  or  the  early  -prine', — ami  .-uh^ided  ai;ain  durinir  the  >innnier. 
JJiit  thi>  can  lie  explained  in  anothei-  wav.  Ihuinir  the  cold  >eason  all 
till'  tiu'tors  inthieiieiiiir  individual  di<|)o^iiinM  and  tran.-nii~>ion  ot'  the 
])oi-on,  -Hell  as  want  ot'  i  in|i|oy  nienl.  |)o\<'i1\,  and  o\ci-ero\\dinj:  in 
liadly  \'entilate(l  Imu-e-,  are  iriiieh  nioie  active.  With  the  eoinin;^-  ot' 
sinniner  the  poorer  |iortion  of  the  population  naturally  leuiU  to  seattei-, 
Work  hecouie-  more  pl(  iiiilul,  and  the  eunditions  ot'  life  are  aec(>rdiii<;lv 
inipiov  cd. 

Il  has  alway>  heen  (jhserved  in  ilu'  iar^'cr  cities,  uctahK  iu  HcrliM.  tliat 
ih,'  disease  rapidly  disappi-ars  ainohu''  llie  waiiderinLr.  liMuselrss  portiou  ot'  tlu' 
inliahilaiils  a>  >oun  as  they  licjin  to  >leep  iii  tlu'  upiMi  air  in>lead  el'  secUiuLT 
the  sheller  of  "pens"  and  as\  luins. 


GENERAL   MANIFESTATIONS   OF   THE    DISEASE. 
Sporadic  Cases.— Endemics  and  Epidemics. —  lh(>  etioloL-^v 

of  typhu-  liver  i-  iu  many  n-pecls  pcvuliai-,  ami  this  alone  lends  to  the 
di-ca-e  a  di-tinci  character  of  its  own,  e-ptvially  as  rcjirds  its  ontlm  ak 
and  the  manner  of  its  s|«read.  A  lunulwr  of  features  that  di-tinirui>h  it 
-harply  from  typhoid  fver  and  irive  to  it  a  niarke<l  re-emlilauee  to  tlic 
acute  e\aiuheuiata  ddhe  mentioned.  The  development  and  exten- 
sion of  (he  di-ea-e  dcpeiid~  chiellv  on  the  t()llowiuir  tiietor-  : 

Individual  jircdi-po^ition,  which  i-  pnnticallv  the  same  ti)r  hotli 
sexes  and  all  ac^es  ;  the  immunity  acipiired  hy  one  attack,  which  in  the 
ea<e  ot'  most  individuals  persists  throuiihout  till';  th.'  i^reat  ea-e  with 
which  the  |M)i>on  is  carried  throne;h  the  air;  its  virulence  and  ix'rsist- 
en.'e  whenever  ventdation  is  det'eetive;  ami.  tinally,  tlio  tiiet  that  tho 
di-easc  i-  constantly  pre-ent  in  lint  few  countries  of  th(  earth  and  is 
only   occasionally   carricil   to  other-. 

I  his  explains  why  in  countries  wIkm-c  typhus  fever  is  eiidemic.  and 
the  population  is  pnietieally  saturated  with  the  poi-on  of  the  disease,  it 
IS  only  relatively  endemic  or  sporadic.  liecondiiL'-  di-tinctlv  epidendc 
only  when  a  larjre  numher   of  predisposed  individuals  have  liad  time  to 


] 


'U' 


im.l] 


TYPiirs  }Evi:n. 

I'lillci't.  It  luvcc  fails  to  ;i"iniu'  ulaniiiiiir  |)r(p|Kirtiiiiis  when  it  is  carried 
til  a  ic^'icui  wlici-c  it  i~  imt  i  iKlcinir  and  win  re  the  cntiiv  |M>piihitinu 
i-  acc(inlinM;|y    |iivdi-|Hi-cd    ti.   it  ;  nv   wliiii,   on   tlic  iitlui-    liand,   laijrc 

iiiiinlpcr-    iif    |ircdi-|i(i-cil     individual.-    nmir    into    c Uric-    wlicro    tlic 

|>c>i-ciM  is  (•(Mi>tantl\  picscij,  a>  i.ccnr-  in  time  nf  war  or  in  i^rcat 
liMLiiiitiirv    niovt  iiK ills. 

Tliat  tlie  pn-t'iici'  of  tla^  poison  i-  an  aii-oliitcly  essential  factor 
niider  siicli  circuin-tance-  \va-  -liowii  i)\  tire  l'"ninco-|'riis-ian  war. 
Aitiioiiirji    tile  world    has   nevci'   -ccn  tlic   nioliiii/ation  of  t:reatcr  nia.-ses 

"f'  "I'll  than  iirrcil  at  that  time,  typhn-   f,ver  did   not  develop,  while 

typhoid  tever  and  dy-ciitcry,  which  have  an  entirely  different  etiolojxv, 
(•lainnKJ  innnniei-;il)le  victims.  'I'lie  wide  disii  ilmtion  of  tvphoid  tever 
is  one  of  its  chief  points  of  di-tinetion  from  typhus  tcxcr.  'I'liiis,  while 
typhoid  fever  oc-iir-  sjioradically,  or,  at  lea-t,  anion^^  a  r.lalivelv  small 
niimher  of  patient,-,  and  li  ■cine-  epidemic  only  when  the  amoniit  of  the 
infective  material  is  as-i  ntal'y  increased  in  river-  and  watcr-svstems, 
typhus  fever  is  scarcely  ever  confined  to  -in^de  cases  or  hoii-c  e]ii(Ieniies, 
an<l  then  only  under  -p.cial  circinn-l.iiicc-.  It  rcirnlarlv  assumes  the 
form  of  a  trciiiendt>i;s  epidemic  whenever  the  coiitacinm  invades  a  [xipii- 
lation  that  is  not  protecte<l  hy  constant  exposure  an< I  that  lives  amid 
bad  social  and  liy;ri<'nic  conditions. 

Epitome. — Our  discussion  of  the  etiolony  may  he  epitomized  in 
till'  following  eonclu-ions  : 

Althoutjli  the  cause  of  typhus  fever  h.is  not  as  yet  iieen  determined, 
it  is  ceilaiii  that  the  disease  does  not  ari.si'  spoutaneou-ly,  and  that  it.s 
development  and  distribution  depend  on  the  action  of  a  specific  eausp 
that  is  priKluc(^l  only  in  the  body  of  an  individual  affected  with  the 
disea-e,  and  that  is  traiisniitte<l  by  him  either  directly  or  indirectly  to 
other  pre<lisposed  individuals. 

i'lie  ilis|;osition  to  the  disease  is  universal.  Otlior  thinjr^  beinij 
e(|iial,  all  aires,  exc<>ptinir  intiincy,  and  both  -exes  are  eipiallv  attacked. 
The  eoiidilion  of  the  individual,  es]iecially  a  depraved  state  of  nutri- 
tion and  loss  of  vital  enerjrx  due  to  the  ert'ect-  of  poverty,  hiuijrer,  and 
disease,  exi'rt-  an  enormous  iutlucrice  mi  the  di-position.  Tvphus  fever 
Is  the  disease  of  povertv--strickeu  and  -iifl'crinir  iiumanitv,  and  it  always 
follow-  in  the  wake  of  war  and  mi-er\-. 

The  i;rcat  majoriiy  of  iiidividiial-  aci|uirc  immunitv  liv  one  attack 
of  the  di-ease. 

The  way  in  wiiich  the  irerms  leave  the  bodv  of  the  individual  in 
wiiom  they  arc  produced,  anil  the  |Kirt  of  entry  by  which  tliev  gain 
aeces-   to  the   body,  are   not   known  ;   it  is  probable  that  the  respiratory 


i'i:i:iiisi'i)si\t;  ( os/ii j/tixs. 


499 


oryaiK    ,in<l    ti,  ■    rxt.nial    -kin    |il:i_\     tli.'    iiio-t    iiii|„,rl:itil    /■,;/,    in    i|,i-; 

I'll.'  <rrnu>  uf  tlio  cli-cuso  aiv  inn>t  |,l.ntitiil  in  tlic  imnic.liatc  uvu^U- 
i)ui-|i,.(iil  ,,!'  llic  pMticnt.  iinil  they  ;irc  r;irric<l  l>\  (|ii>t. 

Tii.'v   iillac'ii    tlicMi-cKr-   witli    irivai    tcnacilv   in   tlic   \arion-   ul)jcct> 
that  (•onic  into  diivrt  .■..niact   uith  tlic  patient  (,r  tiiat   liaw  Imvii  r\{>,,^vd 

'"''"'-'"■'■ 'i"J-'  ■lii--       111    llii-  «a.v  tJK'  .li-.a-r    niav  ivinaiii   .Idfiiianl 

tor  a  Inn;:  ["Ti.MJ  ,,f  linir  and  may  lie  cairicj  to  .ii-tant  |ilac.-  cnlii-flv 
tivc  fidni  thr  .li-ca-f,  <a'iviini-taiic.-  that  lond  color  f  the  torincr  theory 
ol   spontancon-  dcvclo|)in(nl. 

I'Icnty  of  livsh   air  and    u I  N.iujlali vert  an  imdouhtcd    iiiHu- 

oncc  in  iv-trictiri;:  il,,.  ,,„,,„|  ,,,■  ,|„.  ,|j,,,,„,  (  •,,„ vcr-cly.  als,,,  the 
yit;tlity  ot'  the -enii-  inerea-e-  in  dirert  |,ro|,nriion  to  over<T.,\v<linu- and 
iiiaile(|iiate  ventilation. 

The  trerni- do  not  a|.|H.ar  to  l„.  ,-arried  l,y  |i,|,n,i  i,„,,|ia,  |,.a>t  ofall  hv 
water;  n,,r  .!,,  they  appear  to  iv-ide  in  tl„-  -oil  or  to  have  ativ  ,-peeial 
relations  with  it.  as  ua-  ti.rnierly  ,.rron,.,usly  h.liev.W  oftvph.iid  -erni-. 

The  -nni  total  ..f  eiioloirj,.  (;„.,,,,.  ,, ,.;],.  ,.^[,|.,i„,  d,,,  ^"......j  ,,.J,  ^^.j,,^ 

uhieh  th..  di-ea>e  spread-  an.l  it-  p.culiar  trn,|,,wy  to' appear  in  epi- 
<le.nies.  It  al^.,  ...xplain-  why  the  di-,a.-e.  u  hen  iniporte.j  into  rejrions 
where  it  is  not  ..pideinie.  Hrsf  attacks  the  poorer  |M,rtions  ol'  tlu'  popula- 
tion and  sp,.nds  its  ir.vatest  ii.nv  anionir  t||,.,„,  „„d.  \f  it  sp.vads  to 
the  l...tt..r  .•ia.-ses  at  all.  <loes  s,,  only  it.  severe  epitlen.ies  uud  when  the 
disease  i-  at  its  highest. 


^'   iKilil 


« r:ii^': 


'   '^M 


PATHOLOGY. 

GENERAL    FEATURES. 

THE  STAGE   OF    INCUBATION. 
LiKK  tlif  otlicr  atiitc  iiill'ctioii-  .li-c;i-o-,  lyi.lni-  fever  lia-  a  st;i<:e  oi" 
iiicuhatiiiii— tliat    i-   In   -a\-.  a  |ieri(i<l    iiiterv  iiiiiiir   lietvMeii    tlie   etl'eelive 
ilKMulaliiiii  111'  llie  l)atieiil  and  tlie  tni<    iH^'iniiiiiLr  "f  llie  ili-ea-e. 

hi  till'  irreat  iiiajiTilv  ..f  <'a--e-  rlie  ;>atii'nt-  are  entirely  free  frmu 
-yni|ituin~  ilurini:  tlii-  iierii"!.  <  )nl_v  i.eea^innally  do  tliey  eonijilain  nf 
iniletiliite  :-viiiiitiini-,  -neli  a-  lieadaelie,  vertiL'".  I'ain  in  tlie  liaek.  loss 
(,l'a].|ietile.  faliLnK.  nr  depn-H.m.  In  a  !'<■«  in-taiiee-  e(,ry/a  and  emi- 
innelival  catarrli  lia\e  lieen  imtieed.  In  llie  ea-e  ..f  two  individuals 
who  i>-  111'  infected  in  tlie  liii-|iital,  nnder  my  jiei'-nnal  di-ervatinii, 
tliri  'A  ei-v  -liu'ht  fever,  witli  |.raetieally  imrinal  daily  vafialimi-. 
Tlie  len-th  (if  the  |ieri..ii  ,.f  iiieiiKatiMn  -.afie-.  (.uinir  tn  -miie  eaii-es 

n.it  a-  vet  verv  well  kn"\Mi.       I  a^Mv.'  with    iim-t   ;nilliMi'-  in  i -iderini: 

till'  n-nal  dnratinn  to  lie  tVimi  ei-iit  t"  IweK'-.  al  nm-t  'f.nrteeii.  day>  ; 
liiit  a  dni-atii.n  nf  tVniii  fniiv  t"  -even  day-  lia-  niM  ;itedly  liei  n  i.li-erved. 
On  the  iitlier  h.and,  an  inenl.ati.m  ^taL'e  i-f  three  unk-"  diiratimi  -hmild 
alwavs   lie    retra riled    with    -ii,-|iieiiin. 

A  few  eases  have  heen  reporled  in  the  liteniliire  hy  reliahle  aulliers 
1  Mureliisoii,  (ierhanl',  in  uhieli  the  iiiruhaliini  \\a>siiil  to  have  la>teil  only 
a  duv  or  hilt  a  few  hour-  The  ^llol■to^l  |iirio,l  ie  my  .■N|ierieiiee  wa>  loiir 
days.  This  wa>  in  a  mail,  fortv  \ears  of  n^'e,  romin;..  Inaii  a  loealily  alMi- 
liiteiy  uhove  siis|iieioii.  who  had  taken  part  in  ifrtaiii  feMivilies  :.  a  |iiililii' 
hou^  where  he  had  heen  a  >traiiL:<T.  Four  days  later  he  was  atlarkeii  hy 
the  first  iiiaiiife^tatioii  of  the  disea.^e.  Iiiiniediately  after  the  listivities 
referred  to.  the  i.,  ikeeiH'r.  his  wife,  one  ehild.  and  .-everal  retrnlar  patrons  of 
the  place  developed  tvphiis  fever  and  were  adinilted  to  the  la/aretto. 

The  -tateiiioiits  of  some  of  the  older  writers  (Ilayarth.  I'>arallier  and 
Clieyne.  15aiikroft  -  in  reirard  to  ea-es  in  wtii.'h  the  ineuhalioii  peiiod  lasteil 
from  one  and  a  liaH'  to  six  monih-  are  due  iiiii|iieslioiiahly  to  errors  of 
ohservatiou  or  diairiiosis. 

THE   SUBSEQUENT    COURSE   OF    THE    DISEASE. 

The  siilisc(|ii(  nt  eoiir-p  (if  tlie  di-ease  may  lic-t  he  de.-cniied  liy 
irivini:  the  hi-ti.rv  of  a  -evere,  \vell-develo|>e<l  .a-e  in  a  lieal'hy  adult, 
endinir   in   reenvevy. 

I'lilike  tvi)lioid  fever,  lint  iiiiilar  to  the  acute  eNantheinata.  -putted 
fevi  r  iireseiit>  a  narkalile  uiiifurinity  in  its  chief  iiianifestalioiis,  in  its 
&00 


I'Mllnl.ncY 


501 


iliiniiioii,  and  ill  tlic  lom-c  ami  iikmIc  ..f  ii-   iiTiniiiaiidii.      In   all   laivc 

(■|iiil(iiiii--  iiol  inaikcdiy  inuililicd  liv  rMiiiiai  c lition-,  c-iicciallv  -ucial 

■•.  'Ik'  rliaracirii-tir  |ii.'tinv  i>  the  -aiiic  in  ii,  main  fcatiiro.      A  i - 

liai-i-uii  of  tli<.  ili~,a>c  a-  we  know  it  to-day  witli  the  d(MTi|)tioii-  ot' 
older  aiillior-.  >|io\vs  that  it  lia>  not  cliangid  in  any  i'»cntial  particiilar 
ill  iIki  coillSf  ot'   tiiiic. 

1  III'   on-ci    ot    tlic  di-ca-c   i>  almost   always  al>rn|it.      The   fl'vcr   is 

ii>licrc(l   in   liy    one  or  two  di-tiiict   cliill--,    or,    i ■.■    rarciv,   liv    <'liillv 

M'lisilions  la^liiit:  tor  ~f\cral  lioiir-  or  an  ciitirf  da\ .  Tlii-  in  ino>t 
ca.-cs  ciid^  ill,,  true  initial  >tai:r  ot'  llir  di-cax.  In  roii>c,|iicncc  of  tlie 
-nddi'ii,  violent  on~et  and  tiie   ra|>id    ri>e  ot'  teniperatiire  with  eliill>,  the 

patient-  are  viiy  nmeh  pro-tralcd  \'\ i   the  (piit>et.      .Mo-t  ot'  them  are 

<|uit..  miaide  to  uoik,  and  take  to  their  lied,-.  <iii  the  fir>t  dav  ;  while 
even  tho-i'  who  po-es>  a  jri-eat  lV~i>taiiee  11,-lially  ^rive  up  nil  the 
.-ei'oiid  or  thiril  day  ;  I'oii-eipieiitly,  me<lieal  treatiiii'iit  i>  >oiij:lil  iiiuc'h 
earlier   than    i-   ii~iially   the   iM-e    in    typhoid    t'ever. 

Jheehill  i~  either  aeeompaiiied  or  llillowed  iiiimediateiv  hv  naii-ea, 
voniiiiii-,  a  -eii-e  ot'  piexiire  ill  the  epiua>iriiiiii,  aii<l  ]iaiii  in  the  hack, 
the  patient  from  the  very  heirinninu'  lyiiiu'  pa-ively  in  ImkI  in  the  doisal 
l>o~itioii.  Tlie  t'aee  is  tiveri-li  and  r..<l,  pre-entiiig  a  jieenliar  edema; 
the  eoniniietiva"  are  u-iially  very  iiineli  eon^i-t(W,  and  seerete  (•o|)ioii>lv. 

The  miieoiis   memlira f  tiie   nose   and    palate   in  many  eases  hoeonies 

l">;;j:y  and   reddened   as  early  as  tlu^  eveiiiiie;  r,f'  the  rir>t  day,  and  the 

I'-'t'*'"'-^  '' l'l:iiii  "f  a  fee! ill!.- of  dryness  and   >erat<'hiiiir  in   the  throat, 

or  even  of  marked  dys|ihagia.  While  the  mind  i>  iiMiallv  clear  except 
for  a  >lijr|it  de|)rev>ioii  and  ajiathy  diiriiiir  the  (hiylime,  marked  distiirh- 
aiices  of  the  s-n-oriiim  l.eoin  to  >iiow  tliein>el\c.  toward  eveiiiiij:  or 
•  inriinr  the  iiiu'lit.  The  patients  l.e^ri,,  f.  lo^.  interest  in  their  surroinid- 
iiitrs,  ea>ily  drop  the  thread  of  a  conversation,  and,  if  left  alone,  have 
<listiirl>ini,r  ilreams  and   talk    in   their  slee|). 

After  the  ejiills  and  the  nausea  and  vomiting-  have  siihsidiKl  the 
lever    rapidly    ri-^es.    and    a    dull,    tlirohhinjr,    sometime    violent    and 

stal.hinjr    headache,    vertii:..,    Miid    tiniiitiK    aiiriiim    he.'.mie    pr incut 

syiuptoiii-.  Some  individna'-  siitVer  from  violent  pain  in  the  sicral 
reui,,n  and  cannot  rest  ca>ily  in  ai<y  pu>iti<m.  while  other^  comphiin  of 
tcariiii:  and  .Ira^r-inir  i)ains  alonir  the  larue  nerve-triink>.  especially  in 
til.'  le;.rs  or  of  hvperc-thcMa  in  the  filljrer-tips,  toe>,  and  >ole-  of"  the 
feet.      I'aiii    in    the    joints    is    rarelv    present. 

The  tonirn.  i>  treiiiuloii>  ami  drv,  aii<l  helinv  the  .■ml  of  tli.'  first 
tweiiiy-f.,ur  to  thiriy-Hx  h.  -  it  ha-  l..r..m.'  .•..v.'iv.l  with  a  dirtv, 
ycUowi-h-l.rowii  exudat...      Th.Mlrvne-  of  the  other  niu.'oii-  meinhi-imes 


m^ifM 


:a)2 


rvriirs  ji:\i  i: 


lice. .UK-:  riiorc  iiKirkril.  ilic  -udlin^  >>{' \\\>-  pl!:ir\  n\  :!n(l  ti.ii>i!,-  iiicrc;i>(>, 
ami  llir  |i:iliciit-  ('Miii|ilain  Ijitlrrly  of  a  lai^iiiu-  tliiisi. 

'I'lic  a|)|Mlilc  i«  allM.^vilicr  |,,.i.  'I'll,.  alMloinni  i^  ii.iilicr  -u,,llrii  imr 
paiiil'iil.  <\r(  i.iiiiu  III  llii'  (■|iii;a-lii<'  ivuii.ii,  wliicli  in  maiiv  |)aticiil-  i~ 
V(  TV  -cii-iiiw  I,,  till'  tniicli.  Ill  the  1  »■;; imi ill"  :iiii|  iliM-iiijr  the  ciilirc  tir~t 
unk  ill.'  JMiwi'U  ai-i'  il-iiall_v  roii>li|iati'il  ;    rai'rlv  tli,  re  i-  (iiall'lir-i.     'I'lic 

.-|llrcll     ri;  I,     1,1    lli'is    /„,in,l.    ]-.    W |    l,y    |„.r,.||,,i,  ,ri     allll     |)a  1 1  111  I  loll     t(.    Ill' 

(li~tiiii'lly  ,iilai'-i'i|,  a  I'ratinv  llial  i-  rliaractcri-fir  of  tlu'  ili-iaH'  ami 
foriM- :i  n-i'inl  iliai;iio-tii'  |i..iiil   in  tlii'  ilill'civntiation    IVoiii  lv|)lioi(l  \',\tv. 

Till'  |iro-lrali.iii  liHTia-r- -o  rapiilly  llial  iiio-t  [latii'iil- ari' lianlv  al.lr 
to  HI    ii|i   iliiriiiM    til,.    tii-H  ,|;iv.  ,,f  ill,,  lir-t  wi'ck  ;    Inn.  iiotwitli.-tamrnii: 

flii'ir   la-Hliiili'.  till  \    I..-  alMiiit   i',',tl.'"ly  in  Im'iI alilr   liay  or  iiijrln  to 

olilain  I'rin  -liiiit^  -li'i'|i. 

rill'  l'i'Vi'i--i-iii'\  1'  ilillir-  (Voni  that  of  ty|iliiiiil  frviT  in  tliat  it  ri-c,< 
nijiiilly  on  tlir  lii--t  fru  ,lay-,  rrarhinu  a  ronMilrraMi"  livinjit  and 
i'\liiliiliiiU'  -liiilil  ilaily  Nariatioii-,  uliirli  ilo  not,  a-  a  niir,  ex.-, nl  lialf  a 
deafer.  ll  [lartaki'-.  of  tlir  rliarartiT  of  a  lonliiiiicil  frvi  r,  of,  inofc 
rarvly.  of  a  rontiiiiiiii  rnnittint  t'l'Vrr,  ami  rarly  attain^  an  I'Vcninir 
ti'iii|ii.ratiiiv  of  1(1  C,  altlioiii.|i  in  m'Viiv  ia-.i'~  ami  iiritai.lr  iiiili- 
viiliial>  it  may  rravli  frmn  Id..",  to  11'.  'I'l,,.  tiniiiiTatiirc  rafclv  iiill.« 
lii'low  ;'.!•     ill  till'  iiiofniiiix. 

W  illi  till'  rapiii  ri-r  of  tiiii|ii  ratiin.  tini-c  i~  a  rofi-c>|iomlinir  rapid, 
imintmiiiiti'il  ri-r  in  tin  t'ri'i|iiiniy  of  the  |.iiIm..  K\,n  in  vipiroiis 
nun   the   |>nl-c  n-ually  icailn-  liiOon  the  fonnoon  ot'  tlir  mi-oihI  dav, 

and    in   tlir  ivinini:    1 r-    it    ri-r-   to    110  or    TJO,  wliilc    women   and 

rliildnn  show  an  cv.  n  ;:r(ati'r  I'Xiitaliility  in  tliis  ri'spcit.  I  liavc  ni'vcr 
.HTP,  in  till'  lii'irinnin-  of  ty|iliii>  fi'vif,  tlir  ili-|iro|.oition  hi'twii  n  the 
|)iil-r-i-atc  ami  tlir  t<ni|(iratiiiT  tliat  i-  so  vaiiial.ic  a  dia<rnostic  feature 
(if  Iyi>iioid  li'vcr,  and  that  is  .m.  freinieiitiy  olj.servwl  in  yoiinf:  men  witii 
typhoid. 

Tile  arteries  in  tlie  lieLMniiiiifr  are  .soft  and  tiie  pnl.-e  i-  iiornai  in 
voliinie  and  ten-ion.  Tiie  dierotisni,  eiiaraeteri-tie  of  t\|.hoid  fever,  is 
ali-eiit  diiriiiti-  ilie  tir-t  days,  and  .soiiietiines  later,  in  iiv  far  tlie  n-reater 
niiiiiliir  of  ea-i's. 

\\  hiie  the  fever  and  otiier  ^reneral  distlirhanei  s  are  nmleriroinjr 
a  rapid  and  iiniiiternijited  rise,  tliere  appears,  I.etweeii  the  third  and 
the  tilth  day,  or  oeea-ioiially  lieti.re  that  time,  a  phenonienon  tiiat  is 
iiio-t  iharaeteri-tie  of  tlie  di-ia-e  and  oiteii  deteriiiiiies  tlie  diagnosis. 
Tliis  IS  the  ro-eoloii-  eruption.  It  appear-  at  !ir-t  in  liie  form  of  pale- 
hmI,  hvpeii'inie  |iatelii-.  varying-  in  -ize  fmm  that  of  a  jiin-liead  to  that 
of  a  lentil,  eiriular  or  ol,|,in;r  in  -liaj.e.  and  haviiiLT  iil-deliii(.il  iKlgcs. 


Sir 


r.triioi.iK.y. 


m\ 


Wlii'Il  till'  I■;l^ll  (ll'\(]ii|>-  lllliliii  l;.l\  ,  llic  |i;lt(ll(>  ;i|i|Har  lil>l  oil  tllf 
ll)\\(l'  kIuMIiII     IlMll     nil     lllc    cllc-t    llllll     ~||(  illldcl'-.  I'IlcIIi'I'     tlltV    -jirfMcl 

at  (line  lAcr  till'  liack  ami  cxtiriiiilio  iluuir  to  llic  dnr-al  -iirlacts 
lit' tlie  liaiuls  ami  liit  willi  >ii<'li  ra|ii>lity  tliat  the  ultimate  iiiiiiilx'r 
(if  till'  |)atcli('>  i>  ii-iially  icaclicil  within  t'lotii  tiiit\ -(■i;.'lit  In  H'vciiiy-twu 
lioiir--.  Ilii'  paliii-  <il  llic  liami-  and  -(pjr^  nf  ilic  i't-ct  aliiici-t  alwav-; 
(■sca|)(',  and  1>\  far  in  tiic  L:r<':it(i'  nuiiil)ri-  nt'  ca-c^  tlic  lace  a-  well,  the 
ia>l  licin^  -iinplv  vciv  hhkIi  i<'ddcmi|  and  -woUcm,  and  (ittcn  a»ntiiini^ 
an  ah-olutcl\  niicannv  ('\|(i-(~-iiin  nn  acnunit  ul'tlii'  iHldcnini:  and  iicin- 
(iri'liaj^ic  injciticm  u|'  tlic  cnnjunctiva'. 

Siniidtancnn^ly  with  the  riu|itiiin  nf  the  i-oscula,  or,  in  irritahlc  indi- 
viilnais,  l)ct'i)!o  it,  a  incaslc-likr  i-a-h  niakis  its  appearance,  atlietinj; 
with  prediieition  the  extenxpi-  -inliicis  nC  tiie  tiii-eariMs,  tiie  lejr>,  i'he>t, 
and  alxloinen.  This  liide>  liel'oie  the  disap|M'afance  ol"  the  typical 
iTiiption   anil    leaves   n<>  trace. 

Dnrinji  this  |)criiid  <i|'  the  disease,  vhieli  is  nl'ten  desijrnatcd  tlio 
stadium  cxanthematienm,  many  patients  present  marked  disttirhances 
ut'  eonseionsiiess,  even  dnrini^  tiie  davtimc.  Their  iiKivenieiits  hecoine 
niiii'c  abrupt,  and  they  lose  all  interest  in  their  surrDundiiifrs.  At  first 
loud  in  their  e(im|)laints,  they  hecome  uKireand  more  subdued,  and  eiuuse 
to  complain  (  t'  vertipi,  headache,  or  buckaehe. 

The  toiij^iie  now  becomes  covered  with  scales  and  is  niarkc<l  with 
fissures  that  bleed  easily.  It',  as  happen.-,  in  some  cases,  the  eoatinj^ 
separates,  the  tonjrue  appears  imu>ually  thin  and  pointt'd,  and  its  sur- 
face shines  as  if  it  were  lac(|Uered.  Meanwhile  tlu'  catarrhal  symptoiu.'* 
ill  the  pharyuf^eal  structures  and  in  the  larynx  have  increasiKl.  There 
is  hoarseness  or  even  aphonia  ;  the  presence  of  a  short,  dry  cough  sh()W.s 
that  the  bronchi  are  also  Involved.  This  is  confirmed  by  ausciiltiitioii, 
which  reveals  crepitant  and  subcrepitaiit  rales  over  the  entire  e.\t<'nt  of 
the  lunjrs. 

The  complete  developn.;'nt  of  tlu-  err.ption  usually  marks  the  zenith 
of  the  disease.  The  fever  by  this  time  has  readied  its  heij^dit  and 
remains  stationary  for  a  varyin<r  peril m1  of'  time,  the  teinjK'rature-ciirve 
Usually  prc^eiitiiitr  the  character  of  a  continued  remittent  fever.  The 
a](athy  and  somnolence  that  marked  the  ix'^riiiiiinir  of  the  disetise  are 
now  often  replaced  by  violent  excitement.  Phe  patient  is  quite  uncon- 
scious, and  tind>  no  rest  by  iiiirht  or  by  dav.  Sime  talk,  work,  or 
yesticnlate  in  their  dreams,  either  reviewiiifx  fi)rnier  [htIckIs  of  their 
lives  or  iniitaliiig  their  usual  occupations.  ()tlier>  become  viulentiv 
excited  by  visual  or  auiid  hallucinations.  Thev  iinajrine  tliev  are  bcinfj 
j)ursued  ami  threatemHl  witii  personal  violence;  they  cry  out  aiiij  defend 


!■ 


s^; 


• 


Ui: 


i 


w^ 


mi 


T)  fill  s    II   ill!. 


tliiiM-.l\i-  ;  i|ii\    iiiiii| I  oi'  ImiI  and  iry  u>  (-iii|ic  rinrn  tlicir  tiii-iiirc~  |,v 

tli^lil    kv   Ii\   .iii.irkiiiM-   their  altc  ndaiu-.      Tn  |iliii-   tc\ii-  |iali(iil~  in  tlii-, 

ftap'  ni  tlh    ,li-,a-.'  air  ii |iaral>l\    iiio|-c  clilli<'ii||  i,,  mina:;!'  ihan  aiiv 

(il'icr-,  ami  tlu'  ucik  in  a  uill-lillc<|  wanl  i-  alxnit  a-  cNcilin;:  ,.,,1,1 
fxliaii-tiii';  an  i  a|)i  li,  nrc  a-  dui  i,,r~  c,r  niir-.-  ale  likil_\  t.i  nint  with  in 
tlic  cxciri-c  lit'  ihrn'  |ii'ii|r--i(in. 

Dnrinir  llii-  tirni' — u-nallv  nn  the  m'C(iim1  di-  third  da\  alter  it-; 
iippcaraniv — the  fn-cila  (rM|itii.n,  which  wa- al  lir-t  a  |iiiiv  h\  iMivinia, 
Miidci-5.rii(-  a  |icculiai-  t  ran-tlninal  i^n.  A  ccitain  |ir<i|H,|t  i,,ii  ,,t'  the 
fiput-,  vaiA'in;;  in  niiMilxr  in  (hlK  ivnl  ca-c-,  a-nnic  a  |i,  icchial  t\|pc, 
Mnall  hciniiiTha-c~  a|i|M'ai'iMi:  in  ihrrmtii-  ulthc  |ialcii(-  nv  -|iriadiiiLi  to 
tlic  |M'ri|ihcr'y  aii<l  i\ ciiliialls  o.Tn|iyin;r  the  cnlirc  -ilc  nf  the  crniilidM. 
'I'hc     ni-i'oLc,    which    at     lii-t     w.-iv    pah'    ami    indi-linci,    nnw     lici-.m,,. 

">"•■••  |iini need.      Thcv    Kfc. ■   ((iiiiiir-nil.ircd,  w  ith    ii\  id    icntci-,  m- 

the  ciiliiv  -|Mil  may  a  — nnic  a  dirty.  Miii-h-i-nl  a|i|Maraiiir.  In  the 
MAcn-l  ty|M' (if  thi' di-ca-i-  imi-t  <•{'  the  h-inn-  iindiTi.'-ii  thi-  Iran-liirnia- 

ti(in  :   and  when,  in  aiMitiim.  cntam ~  cii' rxtcn-is c  -nlicnlaiiccin-    hini- 

orrhairi-  makf  their  a|>|icai-an(i-.  the  -kin  may  a  — nine  a  man\ -cokircd 
«lil-ky  a|.|i(arancc  that  i-  |)ii-ili\  i|\    i(rril'\  iiii.'. 

l>iirinir  the  lir  •  half  (if  the  -(cmd  wc.k- — .imdimc-  a  little  earlier, 
sometime-  a  little  later — the  elinieal  |iietniv,  a-  a  whole,  ha-  n,-nallv 
reached  it-  hiirhe-t  developmcTil.  The  |ialiein-  are  .at  ihi-  time  extreniclv 
weak  ami  |ii'o-t rated,  ah-oliitely  a|iathetic,  and  cut  oil'  from  the  external 
world.  'I'he  heariiiLr  i-  ]iraclically  li.-t.  the  -peech  i-  mmnlilinii  and 
uiiintelliLdhie,  and  the  eye-  are  ^tarin'.f  ;  with  month  wide  open  and 
liaiijrinj;-,  trcniulon-  j.iw.  the  patient  lie-  in  Id  jiickinj;  at  the  Ix'd- 
<'iotlie-,  with    -nli-nlln-    teiidimnn    and    cariiholoirv . 

'I"he  wild    H-e-ture-  and    the    -houtinir,  to>>in<r,   and    -triiu-linir  ceaso, 

.and  in  tlnir  place  we  have   i  < dition  of  stn|ior,  or,  in  <  xtrenie  ca-o.  ;i 

tnie  coniii-viiril.  .\ll  de-i.,  fir  fiod  or  drink  i-  (.nme,  -wallowiiiL'  is 
(litlicnlt.  and  the  urine  atid  fece-  are  (ii-chari:eii  involnntarih .  At  thi.s 
time  there  i-  fre(|iientl\'  iliMrrhea. 

McMnwhile  the  t'e\('r  -till  contimie-  at  it-  oriirinal  heii,dit.  The 
pid-e  i-  more  t're(|nent  and  mncli  -m.aller  and  weaker  ;  occa.-ionall\-  it 
may  he  intermittent  and  irre(_ridar.  A-  a  re-nIt  of  the  loiiLr  coiitimiaiiet' 
of  the  hy|)er|)yrexia  and  the  further  exteii-ioii  of  the  liroiiehitis,  the  res- 
|)n-ation-  are  acceler;it(>d.  -iiperlicial.  and  laliored.  In  era\e  ca-e-  an 
I'xamination  of  the  ehe-t  at  thi-  time  will  -how-  either  a  -imple  h\  po.-tatic 
condition,  a  lohular  pneimionia.  or  ,in  exien-ive  inllammatory  hypostatic 
ci'iisolidatioii  of  one  or  liolh  iowcr  lohe-. 

Taken  all  toiiither,  the  clinica!   picture  i-  woir-e   than  anvthitii;  that 


I'M  llnl.ocy. 


603 


i-.\\\  l.c  iiMM^rmcl  ill  .i.iitc  iiitirti,,!!^  (Ii-r;i><-.  |{iit  rccnvcrv  is  [H.^ihl,., 
rvrn  when  the  .li-,M-,.  ha-  ivar|,r.l  tlii-  .xtiviii,.  .t:i-.'.  KuViimat.lv  tor 
tlic  |.ati.nl-.  it  i-  a  -liar|.ly  -,  IC-limit.d  .■:tH..ti..M  ihat  niii-  a  .('i-tjijii 
<niir-c>  a;icl  licm  wliich  nvnvirv  i~  |M."il,l..  ivcn  in  the  >,.\  .r.-l  ,a>(- 
lir..viiliiii;  the  |.li-  -.l.iaii  .'aii  nianaL'-.'  to  -n-laiii  lii-  pali.nt  Amuv^  (I,,; 
tin  day.  that  riiii-t  v\a\^-c  lMt\\,-.n  tl,,.  time  of  hv.iv-i  iiitosi.ation  and 
the  r|-i-i-. 

Ill  iiio.l,i-ai,.|v  Mvnv  .a-,-.  an<l  i'l  xv.tc,  iiiu ipIicatMl  .'m-.s  ..iidiiij; 

'"    '■ ^'1?'    i'k'    I''^''-    n-iiallv    l«^in-    In    lii!!    1m|u,,ii    iI,,.    tenth    and 

lh<.  turlfth  dav  of  thr  (li-,.;,-,  .  It  ,„av  continii,.  t.,  ih.'  roiirlr.nth  -lay, 
l)iit  it  rank  la-ts  1.,ii-.t  than  lhi>.  With  ih.-  tall  ,,f  trii,|„.ratiiiv  m..'~t 
of  tlic  oth.T  -yni|.t.,in-   l«.iri„  i,,  -nl.-idr.      Th.-  triu(H  ialiiiv-,-niv..  up  t„ 

''"-  '' inaiiitaiii-  tiic  charari,.|-  ,,f  a  ( tiiiii(<i    ivmittcnt   fever.      In  a 

tew  ea-e-  there  may  •iir.  on<    ..|-  tuo  day-  l>etor,-  the.  vvW\~,  a  -o-ealle<l 

licrliihntin  rrit;,;,,  ,„■  \,.ry  marhe.l  variation  in  th.'  tenipenitiire,  :he 
nature   of  whieh    will    I.e  di-ens-nl    in    .jetail    in    another   plae.'. 

In  the  ;,'reat  majority  ,,fca>e-  th.>  fever  fill-.  |,y  Iv-i-,  with  a  step- 
like  eiirve,  rather  than  hy  eri~i-,  «  ith  a  rapid,  eontiniioii-  def.rve-.e..|iee. 
In  oth..rea>e-,  however,  th..  fall  i.  >,,  al.nipt  that  th,.  n..rinal  t..mp,.i-a- 
imv  is  r..a..|i.Hl  within  li.rty-.iuht  h,,:irs.  ,,r  at  ino-t  after  three  .lay-. 
A  .l..ferv..-,.eii....  lastiiiir  fiv,.  .lay>  .ind  ov.r,  \\itli  mark.d  iiit<.rnii-.si,,n  .,r 
irrejrularity  in  the  .nrv...  i-  ..ompainitiv.ly  nir..,  an.l  should  sii^rjre^t  a 
wirefnl   (■xaniinatioii    for  po-^ihle  ..oinpli..ations. 

The  li..^dnniiiir  ef  ,|eft.rvese..n..,.  is  mark..!  I.y  an  improvein..nt  in  the 
pills...  .\t  lir<t  <oft,  small,  ami  .,f  l.,w  t..iisioii,  it  ,|,.,.reasos  in  fre.|iieii..y, 
lis  a  rnl..,  in  (liiv.t  pr.,p..rtion  to  th..  fall  of  the  tenip,.ratnr..,  so  that 
durin-  th..  tir-t  atM-ril,.  .lays  it  n.-i-Kr-  iK.tw.eii  ,S()  and  Km),  but  does 
not  fall  ipiite  to  th..  phy>ioIojrie  pjite. 

The  return  to  th.-  normal  fre.nieney  is  jmidiial.  As  late  as  the 
fonrteenth  day,  ..r  evn  laf.r  in  very  s..v..r..  ..a-e^.  th..r..  mav  l,e  n.ark.^' 
variations  in  th..  pul>..-rate  after  the  sli:,ht..<t  phy-ieal  or  ment^d  .iis- 
tiirl)ani.e,  wlii.h,  nnd.r  n..nnal  ..on.iitions,  would  hav.'  id  eireet.  As  in 
..ther  aeute  inlivti.Mis  ,liseas,.s,  th..  ,«.rio,l  .,f  .l,.f;.rv..seenee  is  fn.piontlv 
tollow.Hl  l,y  l)ra.lv,.anlia.  whi<.h  may  laM  for  from  s,.v..ral  .lavs  t.)  a 
Nv.vk,  th..  oxa.'t  natniv  an.l  ..aiiM-  .,f  wlii..h  have  not  l),...n  s.tisf;„.t,.rilv 
ex|)laiiuMl. 

The  ..iilarir..m,.nt  ,.f  the  spl,.,Mi,  whieh  is  not  pros.MU  in  all  ,.ases, 
..ven  in  the  l„.-innin<.'.  snl„id,.s  with  th..  .•ommeMe,.m<nt  nf  the  smMi.l 
w,.,.k,  wh,.n  it  ..an  no  l.m-.r  I.e  .l..t..nnin..,l  l.v  palpation.  .V  persistence 
of   the  .nlargement   until  the  i.oriud  d'  deferveseoneo   is  S(.  rare  that   it 


t 


606 


/ )  rill  >  1 1  \  I  ir 


Ml^';;i-l-    the    |iii-cnrr    ,<\'    r.,|il|i|ic.il  ii  .11-    ..r    ..t'    ;i     -|.l(Mic    limi..|-    line    to 

NllllC     |-:lll-c     lAi-lillj-     ImI'mI-c     iIic -.1      III'    l\|lllll~      |1   \  I   I'. 

I'll'-  r||;ir:[.  1,  I  ,  (ii'  -kill-li-iiiii-.  -uli-|i|.-  .ll'lrl-  till  i|i-i:i-r  li:i-  nacll.ll 
il-  ln;:llr-l  |ii.  ill,  .lllcl,  «illl  llli'  i\r.|illi.l|  III'  ih.i-r  |i:i|i||i',  lli.ll  ||;|\c 
IUll|(Ii;iilli>     |Ml>i|li;||    i|i;||l:.'r,    (111    hill      |l('l-i-l    lllllil    llir    IiI'I'IihI    iif    ililcl'Sc    . 

Ct'IM*.  Till'  |Hi.,  lli.ll  li-lmi-  ii-ll;ill\  lllllil  f^ii  lir;ilili\  .  fiiivK  -li|V,|,|\, 
<lcv|ii;inialiiiii.  iii.l,  iil'li  1-  llir  -iil)-i(|rii,v  of  llir  11  A  ri'.  I  Im\  rviii;iiii  in 
Miiall    iiiiiiilMr-    a-   iliitv -Ihuu  11,  li\  id.  m-    \  illnw  i-li-nr.  in    -nui-. 

TIlc  -kill    illll-illi;-  lllc   llci'.'lll   of  lllc   trlllilr   -l,li:i     i-   ||ii|    ,|||i|    ,||'\  .        .\  ,  ij,,. 

fc\ir  lir^-iii-  III  I'all,  liinMAii-.  il  licniiiii-  iih  li-l,  a  In  I  ill  main  ca-i'-, 
<-7-|picially  will  II  ijii-  I'l  \  I  I-  Ii.i~  lallrii  li\  cii-i-  m-  ra|ii.|  l\ -i-,  llicrr  is 
pnit'ii-c   >U(al  ill'.:. 

\\  itli    llii    -iili-iiiiiiii-   111'  ili(    rdiiili-  -\  iii|iiiini-  till'   Iniiiriic' i-i!.'-aiii>  its 

liiiii-liii-r.  ilir  I led   |ialclii>  ileal-  ii|i.  aiiil    llif  t  xciirialiciii-    ami  li»iircs 

Ileal.  'I'lic  \..ii  I-  Main-  in  -trciiLrtli  ami  ir-diianrc,  and  lln'  Ihiar-fncss, 
ulicn  due  -ini|i|\  In  ralarili  m-  ii-ii-inn-.  in  tlic  lai  vii\,  di-a|)|)car>  ;  trnt 
iiit'n(|iirnti\ ,  liiiwiMT,  the  laryn;x(al  iiiaiiitr-talioii-  aii- (piilc  xvcri'  and 
]i(  r-i-t  (111-  Miini'  til r  may  lActi  he  incni-alilc 

I  lir  ili-liirlianri-  in  tin-  iiii:i'-li\  c  a|i|iaratn-,  |(articnla?-|\-  tlic  (iianlica, 
wiiicli  i-  i|iiilc  rn'(|iiiiitly  |in-(iit  liiii-iiii:  tin'  -rrond  vMii^.  di-a|i|i(ar 
wilii  tile  -nii-idinrc  III'  tl  t'lviv.  Ml. -I  |i,iii(iii-  \ry\-  mhui  >ii(iw  a 
jr<Kpd  appctiti',  wliicli,  a-  will  ii-.ntiy  lie  -(cn,  il  i>  ijiiitc  satl'  U>  jxratitV 
witii  a  ciiniiiarallN  (In    lilirral  dirt. 

It',  as  ii>iially  iia|i|icn-  in  nm(im|iliratiil  ri-c-,  i  \cii  lictiirr  tlic  li  \cr 
has  cntiply  di-a|)|M  arcd.  llir  1  \inin!.'-  ri-c  nf  tiiii|irraliirc  Ikcchiii-  ic-s 
liiarl<cd  ;iii<i  tlic  patient  pt-  a  little  nninterriipted  -leep,  lie  iiia\  in  a 
siir]>ri-inj:ly  lirief  lime  recover  t'l-nin  a  di-ea-e  that  -iioi-li\  licfnre  iiad 
i)ccn  tile  can-c  of  llic  criate-t  anxiety,  imt  ti>  sa^v  tlic  dopair,  nii  liie  part 
iif  lii<  attcndaiit> 

IJarriiiif  c(iniplieati(in>  and  x'ljiicl-.  tlic  iliiration  uf  wiiidi  e.iiiiKit  he 
fiire.-ccii.  the  end  ot'  det'cr\i'M'cncc  i^  reaciicii  in  tlic  ■.''I'cat  iii;ijiirit\'  <it'  ca>(- 
within  I'rnni  twcKc  In  seventeen  day-,  .and  the  patient  enters  iipim  tlic 
pcrii.(l  (it'  ciiinale-ceiiee.  In  nut  a  li'u  modcnitciv  severe,  mild,  and 
iii)orti\c  tiirin-  ot'  the  di-ea~e  the  felirilc  period  i-  ended  nincli  earlier. 
Cases  tiiat  at  the  onset  wcri-  ijiiite  se\ire  may  reach  the  sta;re  nt"  defer- 
vescence in  froTu  -ix  to  ten  day-  ;  while  the  milder  and  aixirtivc  eases 
may  tcrininate  t'a\oralily  as  early  a-  the  thirii  or  the  lil'th  dav. 

When  dcatli  i-  ian>ed  -itiiply  Ky  the  sevcrilv  of  the  disease — that  is 
to  say,  liy  the    to\ic  ctl'ect  on    the  vital  uriran-^ — -it  occurs  iisnallv  in  the 

middle  or  second  half  of  the  -1 nd  week.       .\   filal    termination  lietiire 

the   ninth  day,  or   as  early  a-  the   lifth  or  sixth  ilav,  oicnrs  onlv  in  the 


Mi)i:i;iii  .lA.i  jiiM) 


.V)7 


niii-t  -rv.r.'  furni- ct'  tlu' .li-.  ;i-f  or  in  iii<li\  iilimU  \\  ith  little  n-i-tiiiL' 
j»i\\.i-.  \'.r_N  \v\\  iiii<<>tii|>li.'iil<'<l,  talnl  .M...-  l;i-t  lon^jrr  tliati  lli.  -,,..imI 
wifk. 

A-  in  all  inft'ctidiiN  (|i-ia«<-,  i-.pin|ilii'alic>n-  aixl  -.iin,  U  nuv  |>r..|.,nL,' 
tlic  niurl)i(l  piufc—  iti(lititiii(  l\  ,  .mkI  i\rnlii:ill\  Nad  i.i  a  !<  tliai  lirmijia- 
tioii. 

MORBID    ANATOMY. 

THE    EXTERNAL    FINDINGS. 

\\  illi    till'    cxcciiliMii  dl'  ||i<     not    \(r\    iiiiini  i >    i'a>r<    in    «  ImcIi    th,. 

>.kin  of  llic  cadaver  -Imw-  pnn iieeil  tiaci-  ><\'  the  eliarac  teii-iie  eniii- 

tidii.  little  that  i<  peeiiliar  i-  tunnel  at  the  aMtii|i-\.  Th.'  ehrd  limlin-s 
an-  ~neh  a-  are  always  idi-erved  in  aeiite  inh'eliciii~  ili-ea-e~,  and  a  dia"-- 
lio-i>  at  the  antii|)-y-lalile  can  at  lie-t  i>u\\    he  made  hv  exehi^inn. 

Ouiti^'   1,(  till'    hrief  dnratinn   .if  thc'   di>ea-(.  t\|iliii-    fever  eadaveiN 

exhibit  very  little   einaeiation.       Kijrnr   i -ti^  i-  uf    n    >li;.dit,  an<l    la-ts 

hut  a  -hurt  time.  Livid  -|K,t-  appear  early  and  in  ^reat  |ir.>fn-i(in, 
and,  MS  in  tnaiiy  other  int'eetiuns  disea-e^  (~eptii-  |iri.ee>si's,  tvplmid 
fever),  deeiini|Ki-iti((n    hetrins  early,   even    in    eoul    weather. 

It  death  incurred  while  llii'  erujitidM  wa-  pie~ent,  ;,'ri'eiiish-vellow 
<ir  livid,  dimly  outlined  patches,  inter>|)er-ed  with  |.etc(hia>  and  larj.rer 
lieinorrha;ri<'  areas,  may  still  he  sc<'n.  Branny  di  Mpiamatioii  of  the 
epi.lcrmis  m.iy  also  l>o  ohserved,  j)artieiilarly  when,  as  freipiently  hap- 
pens, stidamiiia  were  pre-ent. 

Bed-sons  arc  usually  alisent,  heinjr  found  only  when  the  patient  has 
(lie<l  of  eompli<>ations  anil  se<iiiels  la-tinjr  >i'nie  time.  In  a  fiw  cases 
lih!e;,anoiioiis  processes  or  eirciiniMrilied  areas  of  cntatieoiis  f,r;inirrone  arc 
jire.-eiit  on  the  tiiifjers,  toe-,  cars,  and  tij)  of  the  nose. 

Tiie  imiseles,  which,  like  the  fat,  are  not  dimini-lu^]  in  volumr, 
appear  red  and  dry,  and  on  section  often  have  a  dull  sluvn.  f 'crt.iin 
iniix'les,  e-p.vially  the  rin-ti  and  the  imi-ch's  of  the  tliijrh,  oceasionallv 
present  ulcerations  that,  from  the  |)rcsen.v  of  fresh  liemorrhaircs,  are 
seen  to  have  l.een  produced  during'  life.  I'nder  tile  mierr.scope  the 
museles  present  the  chanjros  .leMTihe.l  l,y  Zenker  in  typhoid  fev.  r  : 
simple  atrophy  of  the  fasciculi,  with  irnunilar  ai>  '.  fitty  dejrcneration  ; 
more  nircly,  waxy  dejreneration  occurs,  vhi- '.,  when  present,  is  hss 
extensive  than  in  typhoid,  thus  jx.ssil.Iy  af.e.-dini:  an  oxplan.ition  why 
tlio  jiwuliar  linear  or  macular  cIi.iul'c  jirnducinjr  the  "  tish-Hesh  " 
appearance  so  frpfpiently  found  in  typlioi.'  fever  cadavers  are  almost 
••onstantly    ahsent    in    typhu ;   fever. 

The  hones  and  joints  do  not   appear  to  hav(>   heen   carefullv  invest!- 


•;• 


6(M 


1)  rill  N  /  /  I  /  /;. 


I 


■lf- 
i  "■ 


lihli 


li    'i 


;^:il"l    III    l\|'liii-  li  \  (  r.  Mild   1    ni_\-(lr   li.nr    im    |ii'i-(iii.il    nli-irx  nlinn-    tu 
'■111  I    on    till-    |p..iril. 

THE    CHANGKS    IN    THE    RESPIKATOKY    ORGANS. 

I  lie  |i -|>ii:ili'iA    .ir;::ili-   l'ii(|iii  lit  l\  ,    IT    iml     iv^'ulillU,  |.l> -ciil    ili:i'lifc» 
«it'   vaiimi-    Liiiil-. 

Ill'    'I ;;' -   ill    til'    ii|i|M  I-  .lii   |,;i— aiT'-,  vvlii.'li   aiv   -..  lVi.|iifnt   !m(l 

N\lii'li    ill    iii.iiiv    1  |iic|i  rilic-   1  \i.  ml    In    the   ,|,i|„r    |i..iii,,ii~,  |i;i\  c  alrciiilv 

lie  III    ivtiriiij    I Ir-.iil.nii;    il"'    l;' II' I'al    iliiiiial    |ii'liirc. 

Swilliii-,   mail  rail. Ill,  ;mi|    n  .ii-i -i  j,  ,n    ,,|'   il,,.    miin.ii-    iminlnaiir   nf 

til'-    II"-' ,   |'liai_Mi\,    ami     lai\ii\    an'    an u    tin'    I\|iiral     tlmliiiL'-.       In 

aililitimi  Im  llir-i  ,  Ml-  lilh  II   liiiil   -ii|ii  i-lii'ial  t  r..-i..!i-   i.t'  ilir  niiiinii-   im  in- 

lii:iiii'   ami    i Iiialr    mil: iialiii\    i  iilai-i  im  in    i.f  llir  imi-iN.      (hillii' 

•  illn  '  liainl.  ili|ililliii  ir  iliaiitii-  iii  llir  |iliar\  iinral  -liiirtiiii-,  w  hji  thr 
|iiiiilih  linn    nf  ilir|i    iiliii-,  ;iir   ili-liiiril\    iiiniT  rare.       Ill    a  i'cw   ra-i-    1 

lla\  !■    -rrll    all    1   Mrli-is  r   i  j  i  |  ilil  |  ii  I'ir    Mil  111  I  llallf    ill    tllr    lalV  ll\.  r\tlllllillir   a^ 

tar  a-  llir  l|-ariiia  ami  llir  laiv  i    iMomlii. 

Ill  ii|ii.it-.  Ill'  many  i|iii|i  inii-  \m  liml  inrntinii  ut'  i\liii-i\i'  -ii|i- 
|iiii-alii.ii  111'  till'  |iliar\ii\  ami  nf  -iaiti  lar\  ii-ial  atli  rlinii-,  i  niiilitiiiiis 
|n:niiially  ali-nil  in  nilur  r|iii|iinii  -  i  (  i  |-ir--iiiMr|-,  M  iirilii-iin  i,  Ms' 
|iii-iiiial  iiii-ii\atiiiii-  wii-i'  lit'  a  \  rr\  nnl'is  m-alilr  iliaractcr.  In  alinn-t 
t  p'  !■  lint.  Ill'  till-  ra-i-  II. mini;  In  aiiIn|i-\-  I  limiiil  intrii~r  lar\  iiiri  a! 
tii-ia-r,  inli-i-tllii:  ill  liia|-k.i|  liililriiilii:  ami  -wrilim;  nf  tlir  lillli-niw 
niiiiiiiiaiii'.  willi  .ill  Ilia  ami  iin-inn-  m-  H.-mi-.  l|,i'  !a  ;  iiarticiilaiU' 
(III  llir  |iii-liTiiir  wall,  nil  ihr  r|ii;;|ii||i-.  ami  nil  I  iir  m  ill  i  ir.ll.il  lialliU. 
.\--iiriatiil    uilll     llli-r     ilialli;!-     1     iili-i'l\l'(|     rr|icalrill\      till'    |iic-r||i-r    nf 

]iii'irliniiiiiili-.  wliirli  ill  i\ir\  in-tami-  wa-  I'liiiliiird  ('\rlii-i\i  l\  in  tin- 
mylriiniil  iMilila;,''''.  I  ln'  ••iniilitiiiii  a|i]>far>  tu  lir  ^'cinralK  iiiiilatrral, 
ami  it  alimi-t  aluay-  liaii-  In  mi  rii~i- nl'  tlic  alVcclcd  carlilairc,  uliidi, 
liriiiu'-  in  iinimiliati  riiiit.irt  with  llir  ilri-|ii  r  lavii'-,  i~  i-iiii~laiill\  liallii'd 
liy  till'  ]iiis  niiitaiiird  ill  tile  [HiiNrt  tiirimd  li\  till'  iiimnii-  iiiciiilii'ani'. 
\\  I'irliM'lliaiim  ri'|Kirt-  -imilar  timliii:;-  in  inniii  rtinn  witli  tin'  |iiiriilcrit 
cliaiii:!"-  Ill'  till'  |ili.'iryii\  and  lafviiv.  (  nmiiaiiii!.'  tlir«r  rliaii;^i'-  willi 
tlin-r  nli-i  r\Til  in  till-  -.inir  part-  in  lv|ilinii|  lr\  rr,  niir  i-  -lriir|<  li\  an 
cxlranrdinary  n'-ciiiiil.ii'ri',  |H)iiitiiii^  tu  -iiiiilar  caii^'^  in  llic  two  pi'oc- 
(■»-(■-.  wliii'li  iiii(|iii'<tiiiiialily  .'iit  imt  ~|MH'ilic.  In  tlii'  ilri'|ii  r  aii'-]ia>-ai;('s 
till'  iiin-t  riin-taiit  rindiiiL.'-  rnii-i-i  in  .'i  ratai'i'lial  I'liiiiliiinii  nt'  ilir  trailira 
and  lii'iimlii,  iii\  nlviTi;.Misiially  tlii'ir  linc-t  raniitiratinii-.  a  ciinditiun  tliat 
sliniild  III'  ri'tfafdrd  a~  jiart  nt'  tlic  di-ca-i'  it-clt'  ratlin-  than  a-  a  (iiiii|ili- 
oatinii.  Ihr  miiriiii-;  imniliram'  i-  iiitrn-rl\'  ri'il.  .iiid  I'livrri'd  with  a 
niniliratr  aiiiniiiit  nf  ti'iiariiiiH  M'crrtiiiii  ;  iH'ca-inii.'ilK-  it    i--   tlu'  M'al    if 


Miii:i;iii    I  \  I  i'i\ty 


'it)'.) 


Ii.iii.iril:iv'<-,  rnnly  l;ii^:r  Iti  .  \f,  lit.  CM.  tirniit'  |>.irlii'iilarlv  in  .•;i-.r>  wli.  n 
hiiiiil.ir  <  li:iiii;<- ;iiv  Iniiii.l  in  .ithtr  Mill. mi-  .1,1,1  ..i-,,!,.  iii.iiiliniiK -.  In 
I  ,'M<l;i\,r-  II,  uiiiih  ll„  l.ii\  iiuiMJ  iiiiiiMii-  iii<'iiilir:iiii'  |in-,iitii|  a  iliiil,- 
tlnri,'  iMi'laic  ill.  -;iiii,'  .'.iii,liii.,ii  \\,|,  |, ,1111, 1  iiii,,ii;_r||,,|||  ,1,,,  ,.|,iire 
liriini'liial    tii'.',  iii.'liniiii;.'   il-    liiii'~i    r.iiiiilii  :iti<,ii.. 

Tlii-   <litVii-,>   liniiiiliili-    I-  .  |..-,l\    I.  laiiil  tu  (lie  at.  i.vta-i     i  |..i.ii- 

laf  |iiii'iiiiiwiii:i  wliii'li  aiv  ijiiit,'  liv.|iiiiitl\  toi;,|,|.  1 1  >  |Mi-tal  i,-  .nn.r,.,. 
•'"11  '•'  till'  Imuit  lull.'-  ua-  I'oiiii.i  III  aliiKi-t  all  ;li.'  liiKJi.-  .Aaiiiiii,,!. 
Or.'a-iidialiv    til,  |-,-  w.i-f  lliiii,  j   inliirrt-. 

I  li,'  lrii|ii,'iir\  III  l.iliai-  |in,  iiMioiiia  \alii-.  in  tii,'  ,|itlir,iit  .i.iil.inii-s 
iin.l  in  .Htli'iviii  |...aliii,-.  Wliil,.  M  iii,lii-..,ii  aii.l  li,.  ,.l(l,r  lai-li.ji 
\viit.T~  n-irani  it  a-  a  ran-  ...■iiinvnr,  .  aii.l  -miir  .,\'  ili>'  |,r,iiiiini'nt 
yminjiT  l'"n'ti.|i  ^ili\ -Irian-  i  i'lhiiiiiM.  N.ilii)  ij,,  nut  ,'\,.|i  il.-iTil>c  it, 
"■'•  i"  iHiliii  tiMiii,]  l.iliar  |.ii,'iiinM:iia  ..|'  ,,n,'  ,i|-  -,\.ral  I, .In-  a-  liic 
iinni.'.lial.'  .an-.'  ..t'  ,|..:illi  in  I",  ,„.r  ,-,.||t.  ,,•'  all  ..m-  is|,|,ii-  li.y.r 
cadaver-.  'I'h,.  inliltnitinn  \\a-  .a.  .■,-,|i,i^r|\  ,|, .,,-,.,  aii.l  ili.  r,,l,,r  ,,|| 
.-.•.•|i,,ii  ua-  a  L'l-ayi-li  y.ll,,u  ,,i-  ;,ii  iiiiii-nalK  l,ii-|it  \,I|mu  ,Io-,.|v 
ri-.'nil«lin'_'  tl,,'  a|i|M.aran(v  -.nirilli  -.-.■ii  in  lil,rin..i:.  |in.'iiniMni.i.  It 
r.'ni.ain-  Cn-  lal.r  l,a<'t.Ti,,|.,-i,-  lin  r-tiiralioii-  tn  -li.,u  uIliIlt  tlir  -inii- 
'■"".^     '"    ill''    .i|i|"Mi-:iii,v-    .l,'|H.|i.l-    on    a    -iniil.irit\   ut'  .■an-,',     in    wliirji 

•'•'-'■    '"l"!'    I'li.'niNini.i    nin-l    [>,■   .■..n-i.hav.i    a-   ;i    tvuv    , i|,li,-atioii. 

\\i     niav    ni.nli.,n    in    iia-iiiL--   lli.it    |.iicnni,,nia-    .vi.lrnilv  -imilar   in 

(•liar:i.'t,r  have  l„rn   in  vr  r, nt  tinn-  .il-,.  ,,l,-,.rv.-.|   in  oIIi.t  i,.,';! lilies 

(  Knikcnli.TL'' anil   lli-ann-.liu.iw-,  Ii,ani|Ml.'ii  aii.l   JliLTi). 

A  Ifw  .iiitli,,r-  n-I.'  ill.'  trin-ili,,n  ,,f  |>n.'iirn.>iii;i  into  ^ranirivni-  ..Ctlio 
lilii-shnt  I  liav.'  n.v.T  -...n  -a.li  a  n-,ilt  iMh.w  tho  tl.nii  ..f  |hi.  iiin,,ni:i 
Jii-t  .l.-(i-il.,,|.  Miinlii-oii.  (Ili,— ii,;r,.|-.  ;.||,|  ,„li,.r-  <|,.  n.,t  a|.i..ar  to 
liavc  soon  iii.in\  ,■,-,-  ,,f  iran-ivn,..  It  i-  tin,,  tjiat  I  liav.^  -oon  :.  .'a-.s 
<.f  -an^rivno,  l,ut  tli.y  woiv  all  ,iiio  n,  |.,.ri,li,,n.liiti-  ,,f  tli.'  larvnx, 
wliicli  ua-  .•\r,...,|inL,rly  |)iv\al..nt  in  tli,'  o|iiilonii<'  ..f  |.«7!l,  ui,,|  was 
I"''-''"'  i"  •■^■'■>T  "II'-  "I'  ill''  '■a-.-s  m.'nti.,n,-,l.  In  ..a.'ji  insfan,'.'  tlio 
ii'-Ti.tic  oailila;,r,.  was  iriiiii,Tso.l  in  a  [....•k,.|  .if  i;.ti,i  |,n-  that  lia.l  por- 
('..i-ato.|  into  til,'  int.TJor  ..f  tlio  larvnx,  -.,  tliat  a-|iirati..n  of  tlio  putri.l 
materials  niii-t  lias,-  li.'i'ii  ini'vitalile. 

Kxeept  tor  till'  liiiriiions  pleiirisy  rcirnlarly  |ire-ont  in  pnciinioni.i.  liw 
cluiiitros  wore  oli-erve.l  in  t!i.'  ploiini  :  tli,'  most  (V.'.inent  w.tc  ic-iiv- 
ni..-.s  and  small  eireiim-.Tii.ed  pat. 'lie-  .,|"  lil.rinoiis  exudate.  Stoils 
exiiilates  aro  viTy  rar.'.  wiiil.'  empyonia  .an.!  f.li.l  efliisions  in  eoniioctiou 
witli  imiriij  cliaiiires  in  the  Iniij;-  are  -oniewliat  more  t're(|i!ent. 


J 


J 


oKi 


rvriirs  j  i:\-/:j:. 


fcH' 


i 


THE   CIRCULATORY   ORGANS. 

'I'luTf  i-  ahiK.M  ;il\v,n-  iinilalcral  ililatation  nt'  tlio  licart.  In  cases 
uliiif  (Icatli  iKciii-  iilali\(|\  cuilv,  liic  iiiii^cic  i-  tlaiii)V,  Inalilc,  dull, 
an. I  <<t'  a  v.H, ,\\  i-li  mi  c.lor.  with  (Mra.-ioiiallv  rcdili.-li  -ticak-  and 
liniar  and  |iiin(lalc  tnarkini^'s.  We  un<|nt>tiiinalily  liav<>  to  deal  witli 
tlir  tiii-ni  o|'  inHriiiiii-  niviicanlili-  that  ha-  ivccnilv  Imvii  stu.licd  l,v 
the  aid  "f  niiKlcfn  niicr<p.~c(i|ii<'  tcvhnic  in  tvphoid  t'c\ cr,  scark't  li'Vcr, 
di|ihth(  I'ia,  rtc. 

Ii'  -i.mr  of  the  (.Idc'f  iv|M.rt,-  (.f  antM|isii-  the  cnilcK'ardinni  i,-  dltcn 
(Ir-.riiicd  a.-  dai-k  I'rd  np  hvi.l  in  color.  There  1-  no  doiiht  that  -iich 
chanjrts  arc  due  to  ]H.-t-inoncni  iinliihition.  'I'riie  intlanmiatorv  procc.-sus 
ni  the  ciiilocardinni.  ( -|iccially  in  the  valve-,  ar(>  liv  common  <'on.-ent 
iVirafdcd  a-  ainoiiLT  the  LTeate-t  cnrio-ilic-  in  t\|)liii-  I'evcr.  rcric^ardilis 
a|)|icar.-  to  he  c(|nallv  rare.      1  have  n:'Vcr  -ecu  it. 

Mie  condition  of  the  va>cnlar  -v.-teni  in  tvpliii-  tevcr  has  not  l)ecn 
tlie  -ulijcet  ot'  much  inve-tiixiitiiiii.  In  the  aorta  and  lart'e  arterial 
trunk-  !  have  l^und  iM.lat(<l,  apparently  recent.  pe<iiliar  vcllowish 
jiatches.  It  i-  nnceitaiii  w  hether  the  cireum>crilicd  cutaiiCH)u^  ^ranicrene 
descrilied  in  a  ii  inner  parac-rapli  is  due  to  vascular  chaiitres  ;  and  it'  it  is 
the  character  ot'  tlie-e  chaiiires  is  unknown. 

'I'he  lilood  in  a  ty|)hn.-  t'evcr  cadaver  i-  ilarker  and  more  Huid  tliaii 
normal.  ( 'oairnlatioii  is  distinctly  le-s  inaikc<l,  and  in  the  inajoritv  of 
cases  is  not  oli-crvcd  in  the  cavities  of  the  heart. 

These  tindiiiL'-  tally  with  the  -tatcinents  of  old;T  authors  in  rejrard 
to  the  character  of  the  hlood  taken  from  the  patient  duriiiix  life.  These 
author-  c:n])hasizc  the  dimini-hed  coajrnlahility  and  the  sot'tness  and 
soluhilitv  o|'  the  hlood-elot,  fn  m  which,  however,  thev  draw  c()Hclu.sions 
that  wc  arc  not  di-posed  to  admit  at  the  present  time. 


THE    DIGESTIVE   ORGANS. 

In  addition  to  the  ahove-mentioned  chanLTc-  in  the  pharvnx,  we  may 
include  amoni.'  thi'  alteration-  at  the  entrance  of  the  dip'stive  tract 
oeea-ional  excoriation-  atid  ti--ures  in  the  tongue,  with  mai'cration, 
hcniorrhatre-,  and  even  ulceration  of  the  irnnis.  ( )lder  authors  speak 
o|  the  iioma-likc  dcL.'-ener.ition  of  the  tuucoiis  i  -■■mluaiie  ;ii'  the  mcMith 
and  eliiiks.  Notiiiiiir  of  this  kind  wa.-  noted  in  the  more  recent 
epidetnics. 

The  esnphafrus  i-  almost  always  intact,  and  the  stomach  exhihits 
no  characteristic  alteration-.  Occasionally  small  lieinorrhaLres  arc  found 
in  the  mucoii-  meinlir:nie,  and  in  rare  cases  laceration-  |  \'ir<'ho\\ )  tliat 
duriutr   life    liad    cau-ed   an   admixture   of  liL.od   with    the   -loiuaeln-on- 


!  .■ 


touts.       Ill    additinri    t 

iiK  iiiliraiK'  IK. I    rarely  [ir<-ciits   cccliv 
till   ■ 


Moniill)  ASATHMY. 
()    catiirrlial    ipliciioiniMia,    the    iiiti-t 


611 


iiial     iiiMciiiis 


ni(i>f>  ;    III  (illirr   I 


il    caiial    I-   aliiin-t    alua_v>  normal.       Iiililtrati 


<>|)i  it~  till'   IliU 


on  1)1-  (Ir^iiKTatioii  of 


ii'lr<    i-    iic\cr  tliiiiid,  anil    I 


II-    inc.— 


I'i'vor'.-  |iatclic.-  anil  I  lie   -olitarv  IMI 

'■~        ^ ■•■.,    (lint      nn        II  u->- 

<MU.Ti.'  -lan.ls  arr  a.Tor.lin-ly  iin,-|,an.i:r.l.  \ wy  .„Ta-i..nallv  I  has,. 
<'l»rrvri|  -li-ht  |.n,iiiiMciir,.  ami  -olli'iiin.:  .if  tlir' t;,lli,.|,.s  in  III,.  !,,u,.r 
\«>n\nn  of  th,.  -mall  inr.-iin,..  Tlir  ^lalunimi-  in  tlir  oMrr  liicratiiiv  in 
n-anl   to   the  o.timt.mi.v   of  ini,>tiiial    ulirr-,   i-|».riallv    in    ih,.   .,|,al| 

iiiir-tiii..,   hrtray  an   rrror   in   .lia-noMs.      Tl a>r-   uvrr  iin.lonl.tclK 

"ilrotyplm-"  (tyi.hoi.l  frvm,  u  lii.-ii,  a>  «,•  know  in  pranir,..  ua-  init 
jwoporly  iliMin-ni-i„..|  from  typhn.  fcvur  until    I,,,,-  after  th,.  ,lilV,.ivii.-,. 

I'<'t\v,.,.ii    the    ixv,,    ,li-,.a-,.s    jiaij     Imtii     frnily    ,-talili~h,.,l    ,,n     th vli.. 

^r.  mil.  Is. 

W  hen  i.rr.hym.M-  arc   |,r,.-cnt    in    th,.  -a-tric  ami    iiiti'Miiiai    .,„,- 

nu.n.l.raiic.  tli,.y  arc  UMially  al>o  t;„in,l  ,,n  th,.  |,crit,.nciini.  whi.h  in  all 
other  rc.-|ie,ts   is   tini'liaiiiriMJ. 

Th,.  Iiv,'r  ,!,„■>  n,,t,  a-  a  rnl,.,  ,,r,.~,.nt  any  variati,.n- ,.tli,.r  than  tli,,>,. 
<'l.serv,.l  in  ai'iite  infiitioiK  ,lis,.a>es  jr,.iicrai|y,  nain,.|v.  mark.W  ,.|ilari:v- 
iiieiit,  inerea-,,!  <.onMstcn,.y,  liyfiereniia,  ,,r  ,li-tiii,.t  >i^r,,-  ,,f  ,.|,,„dv 
.''wellinjr.  A  fatty  liver,  whii'li  is  >ai,l  t,,  o,.,.nr  fr,.,|iienlly  ( Kn.ken'- 
Ijorg),  IS  ii,,t,  in  my  I'xperieiife,  a  ,.,iinmoii  ,.<.eiirr(.|iec. 

THE  SPLEEN. 
Tlie  splenic  clianj^ps  are  not  >„  ,.,,nstant  as  th,.v  are  in  tvpl„,i,l  f,.ver 
\\hen  ,l,.ath  o,..-iiiv  later  in  th,.  ,liM.as..  than  iiMial.  the  enlar>:,.mcnt  of 
the  <pl,.cn  is  not  infrcpiently  al.si-nt  ;  whil,-,  „n  the  other  han.l,  when 
<l<M'li  o,.ciirs  helwcen  the  ,.idith  anil  th,-  tw(.lfth  ,lav  „r  ..arliir,  it  i- 
ppa,.ti,.ally  always  pr,.<ent.  Th,.  >e,.ti,in  in  such  .-a-.'s  pn.>cnt>  a  ,liill 
wiiie-r,.,l,  or  ,K.,.asionally  ,larl<-iv,l.  ,.,,|„r:  the  markin--  aiv  ..ompl.K.lv 
l.lMm.,1  ami  the  pulp  i-  .oft,  -oinctin,,..  ,.v,.n  -,.,ni(liii.l  or  almost  tliii,! 
Occasionally  «c  (iml  intar.t-,  ulii,.|i  in  ,.Ntrem-'  ,  ■,.,.„.,  ,„;,v  h.a.l 
to   rupture  (Ja<|iiot). 

Hoth  the  ol,ler  an,|  th,.  inor,    r.-.-eiit  authors  a-rce  ,„ai  ll  ,.  o.viirr,.,,, f 

p  cm,.  ..„lar,^.,i„.nt  ,s  ,i„„.!,  h..,  .V,.,,,,,,,,  „„|  ,|,..  ,|,„,,,„.  „f  ,.niar.r..|,u-i,t  is 
"Hii.h  les>  ,1,  typhus  thay  ni  lypl,„i,l  t;.vcr.  On,,  of  ,|„.  ,no>t  ra.ii,.al  -late- 
m|'Mts,„i  this  point  is  that  of  liarallier  lepiilenii,.  in  ,hc  prison  of  Toulon,, 
Mm  foiin,lspl,.ni,.  ,.|,lar^'eiiu.i,t  in  only  one-thini  of  a  total  of  )(U;  ..a^cs 
("M-I.anl  f,.iii„l  tlu;c,ilarv'...ii..nt  pivs^-iit  also  in  onlv  oiie-thir.l.  while  Miir- 
Hn.soii  rcp..rls  hmlniL'  it  in  two-iliinls  of  his  autopsi,.s.  \  nivsi.lf  i„v...sti- 
fs-H  i  ;^l''.7'".'  '-,^"""l"'i''--""  tvplHis  f,.v..r  pati..|its  iluriii.r  ,he  v,.ars 
rH,,Saml  IM,!..  lak,nirl.'.-.(.  ,.ra„is  as  tli,.  ..xtreiiie  for  a  m.rrnal  spl,.,.ii 
'llciilyi,  I  ohtain,..!  the  fol|o«  iiii:  r,..,ilis  :  Not  ,.nhi,-,.,l  in  l.'l>  .'ascs  "-.il 
lo.lOO  u-rains  in  I  o  ;  ;!IM(  to  40U  ,rr;„„s  i„  ],;  .  400  ,„  .-,o(>  .r,.,,,,/;,',  f ,, . 
■JOO  to  m)  grams  in  2  ;  (iOU  to  TOO  jrra.u.  in  .'J  ;  ahove  700  grains  in  I  rx-e' 


m 


r,i2 


TV  I'll  IS  ji  \i:u. 


".•i.-llic  nil,.,      Tl,,.    r,.|.,ii,,„   ,,t    ,1,  .        I         I'"-""   ■"   •'■!■  :'  'Nn,i,.nil..  ,1,-rrn 

.1-  t;.ii.ui "  ;  , ;  *  :'"^'':r'  r '■■•■■':''  '"I'-v,,,,.!,.  „  „  ii,,,,,,,,,,,  ,„ 


'■    "'Mnu,,,:.'   !:,|,l,.  ,,!'  C:;  ,,(•  i|„.   i;,^,,,,,,,         ,.. 
^Mldrmii 


ISCS,   CMllipij,,!    liy   ,||y   :i>,-i>i;iiit. 


I'l  r-.ATIOS    ,,K    nil     |.|~KA^K. 


Win. II 1   .11   Till   MM. KIN, 
LT„n,>     ^.nnn>.    ^.-nun-      ,.ni,„.     ,.r,„uv    Jrams 


III 
II 
IL' 

!■; 
1 1 

()M  r    I  1 


I  I 


1  I 

!  1  1 


\2 


THE   GENITaURINARY   ORGANS. 

.''"'"■'"''";■■  ^='~    ^'    '-"I'-    ^"■"    ■ I"i-='t.'ly   .■nl.r^,.,'|.   hv,„.,vM,l,.     .,,,,1 

''"";■.""*" '"  ""■  '•'""""•""  "''I"' M.,.,1  ..i,„„iv  -u.-. ^.,„„ 

a.-M  imiijiaralivilv  lr,.,|,i,.ni  ,• |,li,,,ii,,„. 

1..    .Mualiit,  u,    1S7N  .,,,1    l,s7l.    „,  ro„n,l.  ,.n„nn.^  Nl  ,..„l.,v..r~    ",  ,..i  r 

liortioii  ot   ill,.  iii-,.i,i>.  i"iM>.  .111(1  III  111,.  ,,|,|,i,,. 

X"tlii,„   ,.K,.  ,„...„li.,.  „.  ,v,.l„,  ,;.,,.,  „,,  ,,.,.„   ■,  ,,„,  ,„„■,•„,. 

'""■' v'    ''"'   ^"•>""-"n"^"v  ,„„■,    ami    in    ,|„.  p.nii.lia.      (),.,.;,-i,„   ^ 

(■li;iiii:i'~    ill    till.  ,.ni|,iin,.t|.i 


■:i-iiiiial 


'■"""•  ~".^P>'Hi-  ),ivii,,t,iiv  lal„,r  ,„.  Ml„„.,i,,„ 
H-M  to  >l„,u-,|,at  typliii.  ,;.v..,..  Iik„,„„.,  „„„,,  i„n.,,j„„,  .,i^^,^^^^^  .^ 
NCTV  JikcK-  to  iiitcrni|(t  |iiv^;iiaii,.\ . 

THE   NERVOUS   SYSTEM. 

'i;i,.   niTvoii.     ,.-„.,„    in    ,v,,||,|.    ,l,v,.,.    |,a.    ,..„...iv..,|    iittl,.  at„.„tio„, 
'"'-"l-.-„l,n.   tl„.    ,„.„„ii,i,.,„    ,,ar,    i,    ,,lav,    in    tin-    .Mn,,„onia,olo,n- 
Hv,M.n.|n,a„t     ,li,.    .„r,a,.,.    of    ,|,„    ,,,ain,    ,..|,.,na,o,K     hilihratio,,    .:;i,l 


iipacitv  of  ill, .  |,ia  niat,.r,  ami  an  i 


iii'iva-,.  Ill  III,.  v,.|itri,-iilai-  tliii,|.  «|ii,.|, 


■1^    M    nil,.    ..|,.ai-,    may    o,...aMo„allv    l.,...,,,,..    li.inoHia.i,..   aiv    ,1,..    „„m 

;"'':"''"""''^"'^"-'""i I"i'l-n,v,...^iila,.i,v.      Tn,..„„.,iin,i,i.  ,,,„,,,, 

'"    '"■  -7  '■^"■"-  -"^   a.    l,.aM    , .,.,1,.   „nh    in    ,.,.,,aiii    ,.,,i,i,.nii,...       |.„,. 

.-nallv.  I    iiav,.    not    m-t  n  i.li  a  -im.  of  i,  a,  ,l„.  a,ito,.M-,al,|,..       Ham- 

l"U,,,nH,..o,l,,Hian,i.,ii,,|i,i,,n.,..a.,.,,,f,,n,.n|..|,Mn.. ,i,i,  i„  .„e 

o|ii,ii.ini<.  >iii,ii,.,|  1,\    inni. 

M,.|,i„j,,.al    li,.,i,on.|,a.,..    ar.   ,li<,i,„.,|v    „,„,,.    (V,, ,,„,„,.       ,.:,..,,,,    ,„„, 


f  'I 


m 


.S)'.1//'7V>V,l7V>/,or,}-. 

''T'r'  """'"■    ' '-''I   --""■-  -i'l    .v,.:,llaf;.n-,. ,■,,,,„„„ 

•  'iitirf  lirnii>|(liric. 


ol;! 


to  (■i.vci-  ati 


.     *"    ""■"""■'■   l'-'"l.l-n..nl,a„-    in,.,   ,|„.    l.-ain-nl,-,.,,,-,.   •„■,.  ,li 
"'"'  •'"'  ""■'■'■■■'-  '"  '!"•   •'■•"•'■I,i an    l„,.|i,.,,  an.  n„.n.|v  -i.-n.  ,  f 

„1       II-,.  '*  ''    >'UMs   (it     clirDiiu* 

al.-ol.ol,Mn.  .„  ln.,|n,.Mt  in  ,v,.ln,.  f;.v,.r  patimt- 

A>.o,i„.    |,i„a|,.„,,|.,,;„,,„j|„„.,   I,av,.  n„.n,i„n..,l    in.n.a..  in  ,|„> 

;:r7"';'- ;'"'-''•      '■■■■•-'•''  ^•  ••l.an...s  in  tluM.n;iu 

li..t\..us   sv~t..ni.    nut  ini.r     ,    l.,„,>,-,,  '       ^        " 


ii"tliin:,r   j,    1,11, ,„■! 


SYMI>TOMATOLOGY. 

Whereas   tj,,.  anatoniir  ..han^v-   i„   fnlm^  tLv..,- .„■         v     ■    ■    •    ■ 

.--i<e  a  ,l,a,n..s  a,  ,1.  a,.t.p<v-,ai,le  withotu  an  ae..n,-ate  l-n.  J      1^ 

l-st  ,n  w..il-,l,.v,.|„,„.,l,  ..v..,- ■   n„Kl..,.at..iv  ..v..r j  '    * 

;-;-<-    i^n,a,,...ai.t.   ,;,,,..  ....,ai,.,,H,,,;,^^ 

tl-:..-u.....xan,l„.n.a,a.     Al,i.„n;:l,  tl„.  ean f  ,v„|  n'    "       ,'    "    '^  '1^ 

f—t..  exant.„.n,..,a,  i>   -tni    nni. n    ,  J,  '  '        ,    r'i  !  ^    ^ '' 

^- *•'"— ••^'----■:..a,n „ ..et.;n;;:::;::'::;: 


:7";'"'-'-v"'"'" '-''•''-■'''ivia,.a,a,ta..,.,  ;::::z 

='^*'"'t ""'■i.i^li    ill    iinportan..,.  .,nv  ,,(•  In-  r,     •       ,  "'•'"^" 

IHH'nliafities.       In.le,.,!    tl,  ...  etV    ,  ''  ~  ■•""~"""-'al  -r  -■.,uin. 

<-ase  in  many  oiUw  infctiuii.  ,|;.,.,  „■  ■  n     ■  ^'" 

*     ,1  •        ■     ■  '    '"  '•'^*^-- '^  "■••lallv  ni  tv|,„,i,l  (;,v,,r       It,', 

to  tins  nu,.n,-orjrani.H,  that  «e  att,.il.Mt,.  the  n.onl.n-'n      I  ^ 

:::::::::;::!;:':;;!;;;;!';;'■' ---:-".■:-.:',«':,:;; 

i'>'l'"rtan..e  in  the  .11,,,,.     '  1  "'''''  ''  "^  ^'"■''  ^'t-'' 

^''i-i'-n..:.;;:;ir;:i::''z:x:' '"'»■ • -' 


THE   TEMPERATURE. 


Its 


'    .'irr/f      /■    pl{i'S!(./      Iff//         li  i       ■ 


33 


•".1 1 


/■)  rills  I  i:\i:i: 


The  Temperature  .,   the  Beginninj-  and  I,ater  Stages 

''■'"■'-    "-'"'■'■''    '"     '■>   ■•'"■    l  —  il.lv    -     .rn.l.   .lull-,    M,n,v     r;„vh 

■'   '•'•-'"    -'  ■'-^"' '■  '  "■".    "hI   Ih,    I,„,|„.ratuiT  ri..>    r:,|,i,|K     J,, 

tiMl  M-  r:i,lv  .-,-  il„.  ,.^,.,H„o.  ,,r  ,|„.  I,,-,    ,lav  it  n,MV  ,Ar,.,.,|  ;;;,        ,,„|  ,„,, 

''^"■'■'>    '•"^"■'"-    '"   •       •^'•'■■■^" I.n,„.  ,v,ni-i,.n  ;,!•  ,„„  , v  ,lu„  I  .If 

"''■-'■'■•■  ""    ''"■   ''■ll""i',,-   „„„■„„„,  ,l„.   ..,,,, „.n„n,v   ,.„nnMU,-    ,„    ,,,.• 

^"^"'''■•^""'    '"    ''"■   "^'"in^Mrtl,,.   .V ,   ,h„    ,.,„„   |„,,„„|  ,|„,  |„,i,„ 

'■'■^"""'  ""  ''"■  l'i-''"ln,u  (lav,  iv^i-trnM,:  |ii.:,  ainl  mv,,-  \r„,. 
^Hio.l,,.,-  la|,~..,,r,„,,„^-r,„n-  I,,,,,,-.  ui,|,  a  v.n  -lid.t  n„,n,l,„.  ivini- 
•^""''   "     '''■"'■'"'-    "      •""!    '^'"    I'il-'lHi-.       |„    „„,-,    ,,,.-    a.iutlH.r    ,i-.    i- 

"""''""    ll"-'^'M,n^    nf    ,|„.    ,;,„,,|,    ,1,,,      |,,„„|,,,,.     |.-i„        ,>,,^  .|.|^|_    _.^^^.^| 

n.-r  m  tluT,„vr,|i-,iM^lli~lK.~    ,^,,|„„    t,.,„„    ,,,,|„,i,|    I,,,,,,.         ^   ,,,,,,,,^^^^1 


iMv  ..r  ih,.  .li- 


-i.>i 


I  - '  -  <  t  ■ 


J  - '  ■  I 


Fi...  I 


1 


^      -.'V.  rr  fiisn  of  typhll.-i.     Typical  fi 


'vor  riirvc    in  |  art  i|iiiv:Miiiiiniic 


ri-..  i„  ilip  fMiponitmr  t.,  ii-  lii:.l„..t  [.nint.  >u<li  a>  occurs  in  i!:.  hitt.r 
•li-ruM.,  xv,.mM  l.ra  -ival  rx,  ..pti,,,,,  an,l  <.,>.■>  .,f  tv|,l,M-.  luv  ,|iiit,.  (W- 
'l"'''il  in  whirl,  tl„.  |,i„|HM  ,H,int  i.  ,Ta..|„..l  at  tlic  rn.l  of  tl,inv-Mx, 
t\v,.|ify-i;,iir.  or,.\vn  i,,  a  v.tv  \W  Ik.uis  (,.,,|„|,||.,.  j.-jj,  .-,7)_  I)|,|.in,_,  ,|,„ 
Hv,.,,,!  halt'oC  til,.  tii-M  „,vk  til,.  ..urv,.  i„.|.>i-t~  at  tli..  >aii,,.  I„.i-l.t,  w  itii 
MM.,l..rat,.  t,i,,niiiiir  i,.t.ii>-i,Mi~  ti,,t  ,x,.,.,.,ji.i:r  (i..-,^,  ,,,.  it  ,.,,ntiiiii...  tu  ri-c 
-l-wly  until  til,.  ,.i^r|„|,  ,|;,v,  .,,  ,|,„  i„  .,,,,,„.  ,..,^,.^  ,|„.  , |„, ,,„„„„,,, ,,^,^ 
tins  ,,..ri,Mi  may  vv^/^.wv  II  „r„v,T.  Th,.  I.liav  i.,r  ,,f  tl„.  ,.„rv,.  ,lnfini: 
til.,  tiivt  \v,.,.l<  ,,f  til,.  ,liMaH.  i.  M,  v..fy  |.,.,.,iliar  a-  to  l„.  ,,f  tl„.  Iiiuli,."t 
<Ii.-ii:n,,-.ti,.  vain,..  Wliil,..  ,,n  tli,.  „n,^  Iian,l.  it  ful(.<  ,,iit  tv|il„,i,l  |?.v,.f, 
til..  iliairn.iM-  ,,r  any  ,,tli,.r  ,.C  tli,.  ,.xanth,.niata  i-  .-.niailv  iin|,i-,.hal,l,.,  as 
'"  11,1.1..  ..r  tli,.<..  ,li.,>aM.-.,  niu,.l,   as   tli..y  ri-wnl.l..  tvpliiw  f;.v,...  in  u\\m 


^VMI'ln  'l.\Jiil.'i',  )• 


.1 


'-''■   ""■  -anu.   Hm.  a,.!   nniCnnin  ,„'  ,i„.  n.,n|,..ratur.. 

„      1'""'    ';'■""■    '' ''■'■"   ^"" -•'•^"''"•l.vun\VMn,|.Hi..|,Van,l,„mv 

nu-H„„.    ,|H.   ,„.,.a.„„al,„.,.,n-,v„..,.,.ra,.|,a,a,.„.n ln,„  in    ,1,..   ,..,   : 

Z7     r'" "'; ''-'■'■  '■'■'-'■I"  "l—.l„„    i,    .,,.,l.al,le 

;■'"'''•"'■'■•  ;;;•"•■•'•"--' y  i...~,.uai  ..1,..,. ,.;  sai; Z 

"■■"l""-aiy  lall  in  the  U.,n,u.rat,nv  was  noli..,..!  i„  o.,ly  :;  ;,,...  ,  Fi,,   ,;,,. 


Dny  ..r  til,.  ,)i„.„„. 


fi'^.  l'.l.-ro,l,|l,.r.i.i^„,„.,.„j,,,r.,,l,|.     M,,,!,,-  ..,        ..       , 

|.'iy^cv,.r..ca,..,f,y|,,„„f,,v,.,    Homis-i,,,,  ,.„      m    "'      ''— ^f^'""" 
'l"-^'v.-.,n,.„f,h,s,.v..mh,l„y.,fUu.,ii.,., 


iri'iilirc,    scvrntocn   v.-nrs  (,|,1 
I.TMc'ly  scvvr,.  ,.,,„„,..    Mnrkt.t  pn-rrilical 
«»o.        vnrmii,,,,^  in  ,ht  curve  » 


eve:";!:;!''';:::  T'f  '"'"■''  ^^""''  ^-^'''"^  ^  ^'^  "•™-  "'='^ 
^^•^^.^..^.:^:;.::.;':.a:::;:r;;:;:-7'7''-"-^'''''--^ 

;;::'>^--''••■^ ---'-:  ;:::^l:t^^^^^^^ 

In,  I,  ,.  „    a  ...n,n,n,.,l  .vnutton.   typo  in  sn,.l,  c-as-s,  „s„allv  ,.,„..i.t.  , 

P-|.t.l,Io    rcmw.,,.,,    .1„,|„,.   ,1,,    ,„„,„i„^.    ,,„„^^^   ^^.,,    ,  ^^ 

t<'tnp,.n,.nr,.   romai,,-  ron-ta.ulv   l,i..l,.  "'^ 


After  tl...  .entl,  a,„l  .Lventl,  .lays  of  tl.o  .liseaso,  snmcti 


mos  as  early 


51 1; 


7177/r.v  I  i:vi:n. 


a-    till'    niiiili,  ;i    iiiarkiil   cxmiii-    niiii--i,.ii    l.,;.ri,|,    .,,   :i|,|„..,|-  (r,.iii|iMiv 

'■  '-^-     1^   :ill'l    ''I   ).  all.l    lllr  ,l|l\,.   iMCnrju-   .li-liiinl^     iv    irT. -Ill;|l-,  ..\u\\ 

A\i<\\\\vj:  inarL.d  iiilrMiii--iMn-.  In  I  he  -ex  iir-i  ,-,im-,  uhiic  rln'iii,,-- 
iioM-  1.^  viTV  liad,  lli,  •■(Acr  rMiiliiiiK-  hi-h  cvrii  iliii'in-'  ilic  laM  ilav.^  nl' 
til.'  (-.cunil)  u,vk,  and  o.  ra-i-nally  ri-.  -  :n  -ival  luiLrlil-.  In  hicIi 
(-.i-c>  tlic  oniiiion-  |ilirM..nirn..n  ..I'  r,,lur  munhi.r  i.-  |.arliciilarl\  mai-kcl. 
Tlic  iM-inninuntM.'IrrvcMvnrc  in  mwiv  and  nin.jcral.  Iv  -(  vciv  ca-cs 
oiidiiiu'  ill  ivruvny  i-  ni.hd  ai  llic  end  ,,1'  ilir  -,c..nd,  .,r,  ranlv.  dniani: 
llic  (ir-I  day-  ,,ftl„.  tliii.l.  u,vk.  I  nl,-,rv.d  il  ni.-i  rir,|n.nl  ly  Julurcii 
llir  luclltli  and  lla  'ilhrniji,  and  <  a;.  |i!  innallv  <.n  tlu'  -ixtrrnih  ,,r 
the  Mvrniiviilli,  day  (if  ihc  di-ra-r.  Tlic  |i(nnanrm  -nli-idrii.v  cf  tjn' 
trni|M  ratniv  iliai  Inlluw-  in  tlic  -ival  niajdrily  ul'  .aMv-  i-  (icra-idnailv 
prrrciird  l.y  a  |icnnd  ,,f  iVc.ni  iw,  nl\ -ll.ur-  1..  tiilil_s-ix  li..m--  (.-(.nipaiv 
Fis:.  -MM,  .Jnrini:  ulii.ii  iJim.  aiv  mark,. I    variation-    in    llic   cnrvc,  with 

M'vny  and  viTV  aiarniin-  di-lnrhan. v-  in  ihc  iiatirnl'-.  LTiicral  ,■ liiion. 

Not  iiitVcjncntly  llniv  i-  an  rMi-cinr  v'\-v  d'  l(in|Hraliiiv,  to  il,,'  Ik  i.rlii 
oC  41  '  or  r\.ii  l_'  .  liillou,,!  uiiliin  tVoni  lui  I\  i  to  ,.i-;|itiTn  li.uii-  l,v 
a  tall  liclow  tlir  t(  in|)(  ralniv  oj' tlir  prcv.'din--  inomiii- (,oni|iaiv  1'!^:-.  T'^ 
and  (in.  \\lirivn|>on  iliclinal  lall  ky  .ri-i- of  ly-i-  n-nailv  occni- without 
any  tiii-thcr  intririi|,ii,,n.      Tlic  okl,  r  aiilhoiv  ha\c  di>criiicd  tills  hv  tlio 

<'\|i!'c-->i\i'   ti'flll   III  I  till  hiltii,  rrlfifit    {\"'-j:,    o|  I. 

A  r(.iiti-:ify  (|,fccritiral  I'all  |  liiha\  ior  ,,{'  thr  cnrNC  i-  a  di-tini'tlv  rarer 
oci'iirriiico.  Ininicdialcly  |ii-(ci'<linL'-  lii.-  |"  imaninl  -nli-idincr  of  iho 
ti\,-r,  thr  t,iii|irratiiiv  -ii,|,li  nly  falU  to  ih.'  noiina!  or  lulou  it,  and 
within  twelve  honi--  or  le-  r,tiii-n-  1(.  or  a  link'  hey<in<l  it-  former 
lieiirhi.  riii-  -,.-eal!ed  "  |i-eiidoi'ri-i- "  i-  imniedialtly  iijlkiwed  li\  the 
linal  tiiil  in  the  eiirve  (  V\'j:.  '>-2). 

The  Period  of  Defervescence. — The  tein]ierature-coiir-e,iuri,.; 

the  ^tair('  of  ileli'rve-eciii'e  -trii.,iiii.dy  leeall-  what  oe,  nr-  dui'iii;,'-  the 
imtial  st.iire.  '{'he  ahriiplne-^  and  ra|ii<iity  with  wliieli  the  fe\(r  ri^e.s 
are  usually  parallekd  hy  thi'  eom|i|eteni —  with  which  the  temperature 
falls  to  or  helow  the  normal  within  a  few  hour-  or  days.  It  is  not  at 
all  a  rare  oi'eiirrene<'  t'm  th,'  tem|ieratiire  to  tiill  at  one  droji,  usually 
flurine-  the  ni-ht,  tVom  a  eon-idcrahle  heii:ht— Id  and  ahove — to  ;',7" 
or  even  les-  {V]<r,  o.", ).  More  fre(|neinly  this  flill  i-  interrupted  hv  a 
temporary  ri-e  in  the  <Mirve,  the  temi>eratiin'  at  lir-t  -inkiiiL^  to  ;;,S..")° 
or  .'IS'',  and  tlien.  toward  e\enitii:.  nioiiiitinir  1'  or  l."i  hefiire  its 
final  return  lo  thi'  normal,  where  it  then  per-i-t<  praeti'^allv  without 
interru|)tio-i, 

\\  !th    almo-t    e(|iial     fre(|:ieney.    in-tiad    of  this    siiiL'Ie    interruption, 
(he    fall  oi    the   teiiipenUuie   may   pre.-eiii   a   >tep-like   curve   exlendin" 


M  MIIn)l.\ri)lj,(,y. 


tV'ini    llii-fc   (()   li;iir  i|, 


ly-    (iDiii 


|i:uf    i'i:;. 


>  I  ).    "  llllr    Mil    l\ 


gfailiial    iMHliiii^r  ,.|    ih,.   riir\r  l,\   ,li-linrt    K- 


)17 


I'll    iriMi-e 


1-    I-    II 


iiicli  i-aivi-  (  |''i^.  .-,  I 


Km.  :,i,-\v 


Oman,  thirtv-tliroo  vmrs  ol.l      v..ri-  ^  ,.  > 

u.aL,  •  Vr  •  "    ""' l'!"-"'''l  '■>-    with  i.T(at  ..ir.lim. 

Tlir    (,.,„I..„ry  to    mark,.,)    i„t,.n„i~.i„n    .Inrinj,   ,1„.    p,,,.;,^!   „,•  ,!,,,•,,,. 
V.-.M..CS  wlu,.|,    is  aln,„s,    .vpi.,.!   of  ,v,,l,„i,,    ,;,,,,.     j^   ,.,,,.^.   ^j;^,,,    ;,_ 

li:iv  ,if  til,,  .li-.-iivo. 


'It  h 


"'ii)TiT|T;]TaTi4|i5rrferf7n 


Imy  ;  f  til,  .liMi,..,- 


I''I'.  ..-'  M;.i,.ll,,rlv.,.„,.  y,.ar>n|,|  ^.v.r.- ,„-. 
-f  lyyvhus  f.v.T.  l's.u,l„..ri.,.s  ,.„  tl,..  t^.lm,  u„y 
of  the  liiscase. 


Fli.   "'".  -Man,  iiiiirtpi'ii  v,.|irs  ..1.1      M,,,). 
pnit,  ly  s,-vrr.-  .'ns,.  ,.f  sli,,rl  ,li,niti.,„      Iii^. 


lill.'t      fill      liV    (Tisi.. 


"J!i.--,!  i.r,.,Ti;;,.ai  rise 


rrvc'il,.!     !,y    ;,    |,t 


i:    -■ ' 


ii,    -zr 


m 


\  ■ 


:,  I  s 


/ )  rill  s  I  i.vi.i:. 


|Hii,„|    li-iin^r    tv,.)   or  thrrc   il:i\-,  (Inline;  uhidi   ilirrc  arc  .■(.ii-idcfnl,!,. 
Nan.ilioii,  in  ilu-  rmw,  with    low   nKiriiiii-    and  vcia    liinli   evening  teni- 

I   ..-.    -t    Ih.    .1;..    ,-. 


160  40 


HO  33 


123  38 


100 '37 


f. 


■     ■ 


li 


:±. 


8' 3 


TO 


-~r 


so   3C 


:;t 


i-r 


}    ] 


M    12 


ti; 


^t 


rT- 


^m 


n^ 


Jllf: 


J 


!6    ■! 


:.i  -I ; 


« 


St!®^' 


i 


Fl...  .M.-K.,rcn,Kn.  iu,!,i>-,,^ht  y,ar>  ..1,1     ,  ,„„  t  mx.t,.;   -ul,M-,|u.'nl  ,-„„rse  miUl  au.l  M,„rt. 
uilh  11  MTV  i.r.ir.i.l.  .1  |i.Ti...l  .if  il.  r.Ti.M.nri', 

[iriiitiin--.     'I'lii-:  phennineniin  ha-  received  >]ii.cial  attention  iVoni  Kn-eii- 
.-tcin.  \\h(i  a|i|Mar--  Id  liaxc  (il)>cr\  cd  it  lVei|iienll\-. 

\'!iy  ..1  111..  .l;,.a-.'. 


100    V 


60  3e 


CO   135 


Tv,.  .V..-Winnii;i,  t«i-nty  s..  -.■ii  y.  ,irs  ..1.1.    Si-viTr  roiir-..  .lurin-  |li.>  lir-t  w.  .  k  ,  \.ry  sl...rt  .lum- 
ti'.n      l!i-._-illiiiti-  ..f  .l,.f,TV.-r.  t!,'|.  r.ll  til.'  nililh  .l.iy  .f  the  .Ijv,  „,,. 

Temperature  Variations  in  DifFerent  Forms  of  the  Dis- 
ease.—  Fn  -cvcre  ;ind  niudciatcly  -everc  ea-cs  the  I'ehriN  |»>rii)d,  a< 
lia~    iirevi,.u-iy  Ixvn    ,-taterl.  n-ually  ends    lietwccii    the   fiftccnih  and    tllf 


.V))//'/v/.l/.l  /-o/o^  )■. 


''liiiniiiiir  uf  ,A,.,i    i|„.   ,n.|    ,,|    III,     toiirili    ^u,U 


III 


luc'MIiril,  ,Im\.      S lii,,,-.  ihuii^li    raivl\ 

I'l'iil'     iiiilil    till     I,. 

,    /'"-'■^    '''^"     '■■-'"    •"    "■'■"''■>■    i"''"v    III-    .11.1    ..I    111.-    v.,.,,i„|    „,,k 

':'■'""-'"""'  '-i'i"M;,nM-„r,i„..ii-.,,„,    Ti„.  i,.--,.iiiM.r„,-,i,„,i„,,. 

' ■"''■'•'"■'"' ">    >l-    t;-M-iuiii.  .I.inii,.  ulii,.||    III,.  ,„n|„.rani,v  inav   1... 

'I'""'    '"-''■      *'-••"■'■  anill  raiviii  u  Im.Ii  lli.iv  ,~  an  ,.v,.„; „,„- 

'":'■■;""•""'    ' ■"^"'    "     <--l"'-i-'n„.  „n,il,li,.,.,i,|„C,||,.  ,i,„„,vl. 

"'"'    '■'    ' '"'"-    ""'l"raliiiv   ,.f,i,,I    iuimI,    |,,u,r    ,|,ai,     |(i      ,  Kj,.    :,-,,' 

O-lin-.  .•lUMMi,  |„,.-,.,i,  niarl.,.,!  iviii„-i„„-  aii.l  ii,.,.nni--l„n-  of  ,|„.  ,,„.v,. 
«i-iii^>l„.v,.,v,i,-,,hn-,  1,11,  ,.v,  Mill  M„.|i  ,.a-,.-  ,1„.  ,.,„„„.  „,„,„,. 
^""iv  n.-  |„  a  Im,I„t  ,,„in,  iliai,  ,-  ,.,nmionlv  „l,.,-v,.,|  ,|„rinu^  ,l„.  Ii,,t 
"(vk  (p|    ivjilioid  H\,r. 

I'Ih'   iiiiiial   >tai:c  -.il-ii    i~  I'l 


.■.lii.'Mtlv  al.ri.l-nl    in    il,,.    niil.jrr  ,.a>, . 


i"i>  ..r  ih.-  .1,-1 


Kl'.,    -■.- Wiiil.T,  iiL-hli'iTi  v.ars  ..|.| 
Mil. I 


-•  »ith  r.h.tiv.lv  I..W  ,, T.,.  f;';;''"r^'"';-'»''>''y-'l''-'-y."sol.l.    Mil.lcaseof 

I'lr.-.     I'rr.riii.ul  ri-i.       '  ''""-"■'''■  f"!'"" '"^' ""mr.liat.-ly  ui...n  nn  nttark 

■•f  r.,urr,„,   iVv.T.     Al,r„,.t  ri«..  of  ,l„.  „.„„„  nit.ire 
«  nil. .Ml   r,.,„i-i..,,.  un.i  u'ra.lii,,!,  sl,.,,.|jk,.  .LiVr^,.,. 

"''":■    ''■ ;'■';''>•    '"■'•"^'•-    "-■    '■'    "-    -v,.,...   .„,...      T1„.    f;.v..,-    ,nav 

i"t-n    1.^   Ii,.,,l,t    in    In,,,,    .-.|ity-,;,„r  ,„  ,|,i,,y-Mx  l...i,rs.  ..itlw:- at  ,„m. 

'"";'"'  "•■^^■';''='^"'^'"--"l"-n.      An ^  tl„.  ..a.,  that  liav. n. 

'""■'•  '"■:  "l'--va>-"  'Inrinu-  tli-  (iiM  ,lay,  I  |,av,.  n-v..,-  .,l,s,.rv,..l  a 
p    n,     n...,„tl,..,;.v..,.,;,l|„„..,||,vanal„„.,iv, „•...      On, ,|„„, 

;""'•."";•':••""'■"''•■''  —  -•--"- 'V.-.  |-..n-ti.ii  in  ,ui!,!  <.a... 

,    V^'~;"    -"7-  "■"-■  i-    "l,i,.l,   tl„.   n.ur r  ,1,..  ,Ii..a..   N„,„ 

lall.,1    the  finpn-atiMV,  cnverin-    C-nni   inv    U,    ri..|„    .l.,v<    ,l,,>.-.,    ...   ,._ 


o-n  V)  /7/rs  irvrn. 

'■'■'"  '"'""  •'"•  ""'•"'^''  >'■'-•  ■"'-■  TIh  ,I:.IK  v:,ri;>tiu,„  ;nv  ,,-uallv 
'••""['•H:.IIVrlv    -li^l,,.         A    t,n,H„;,li..„     ol'    l!,.    |,.^,.,    |„     ,,i.i,,    |,.,,„„    ,„;, 

'"■■'■'•''•"'  l.-nMu.K..  ,„,.„|„„„„  l,..u,-.  :,|,,„  :„-.„„, I,,., „l,..,.|,:.M,|,,u 
'"     ""  ""'I''   tl''|IH  111    III    iiiiM   ||,:i,|    in   .,.^,.|,,  ,..,,,., 

^''■'•^    Mnl.|,,r,|,-,ii„i    ;,l„,rin,.  |,„,n-   ..f  u  |,h,,i,|  ,;,,,.r   Iimv.   moI    ms 
^"    '■"■"^"'    ^"»    '■"■'"'I    -""^-       M^     -w,    ol,-,.,^:,li„„-.  ,.-|,.,,.i;,lK     ,„ 

'■'-■"■''     '■'     ''"■    '■'""■-'■    •■'■    '!"■     t<M,|Hlal,IIV.    ;„■,     il„nni|.|,l,..         Tl,.-   ;lr,',„„- 

l''"'-^'"-    '^"■"■^"i Vys.   .■..s,---,|„.    h,-,.,n     ,,f   ||„.   ,,,.,.    „i||    |„,    „i,,,, 

lalcT— l„,u-  ||,;„  ||„.  l,,n|„,.:„„iv  i„.,v  n..„.|,  a  .•,,n-Ml,.n,l,l,.  I„.i..|,t",r„.r 
•'  '''I'"'  """^''  '■'-'■■  *'^'-'-  ^^i'l'  ^''-^  1-^  M„|„.n,iiir,,.  ,„.  |,n,r(i,,,llv 
al-l'ni...  -uri.   ;,.    ,1,,.    u,,h„i,|    Cv.r   ,^,„.^,    i-   „,    i;„i,ili;,r  « ill,     |    1,  ,u. 


iiv  ..|  111.  ,ilM-aae. 


Ully  iif  till    .li-.ii-r 


aMt^^il: 


li'.    >  -  Wcimiiii.  thirts'one 

v., IIS  nl.l       .\l,..rtiVl'  I'lKr   i,f  ty. 
I'liu'.  fi\i  r  «  iih  f,  V.  f  i.iisi-t. 


I'i'..  V.i  l.iil..iri  I.  I,,rl)  lui.  y.iirs 
ol'i.  Kxi.'ssiMly  Ii1l!1i  tiiiti.inilure 
iiiiliir.liiitely  |.i,i,.liMK  'itiith. 


ninly  „l,M.m.,l  i„  ty|,l,„.  Cvrr.  l,„t  I  wo„l,l  ,„,(  .ar,.  to  allinn  tl.at 
tliiv   a:-,-   111    ivalitv    raivr   than    in    iv|,!hm<I    tl'v.r. 

I"    tlid-.'  fatal    ■■a-.-,  in  w|,i,.|,    ;:„•    ,,a,i,,,i    .„c.-m„i1i.    t<,   tli.'  severity 
"'     ''"■     ''""^''  ■"!'">     anil     l„,|     t lll|i!iratinM-.    til,.  trMll„.ratlMV-e„m.  i. 

M-nallv  .h,,,,,,.  than  in  ,|,,  s,.v,.,v  ,,nr~  ...ulin^r  ,-„  ,,„.,,vrrv.  Tlie 
,i:ival    iiia,|,,nty    of  mi.-Ii    raM-s    a,,.    ,-liarart..riz,.,l    l,v    violnil    ,„iM.t    aii,l 

'■I'lll   ai"l  •■".  unuMially  hid.  trn.|,..rai,iiv  fV 1,,,  v,,v  l„  .^innm..    with 

"lidit  niuniin..  r,,ni-M„„..  |  ),,„!,  n-iiallv  .„-,.,i,v  l,..tw,.,,i  the  ninth  a-.l 
th,.  tweltVh  .lay-ran  lya^  la.e  a-  the  Hxie-aith  .lav.  A  p..n...,,til,le 
I.n.an-.,ni,.  n-..  m  tl,.  t,.in|.,.i-aiiiiv  i~  a  .■nninmn  iili..n.,.n.Mi.in  (  Fi-  .-,|t). 
'" "''  '">  •■^'^^■^  '■"■  tl"'nnn,iul.a-  ivjriMen.l   \1.2-  ( '..  and  Wunrierlieh 


^)   1//7'"1/  I  inl.ni,  ) 


>1\ 


iv|i..r|.   a 


'•■•i-f   in    uhirh    tlir    t.  iii|.ir.iti 


V'.    .      I 


■\\>U-    1.1    il.  l.rn 


Mij.      a     iiiarl 


"I-     ("  •|ll('ll!l\ 


ill      y\--     III     III.      n-.ial      I 


rlii|M  laliiiv     alliT 


ill 


II 


522 


M    i/l'  I II  \/  \  I  nl  1,1,  ) 


vniliLilini,    ji,    ||„.    i,Mn:,.k     ,,i    \l,.,l.ii   u:,.    ,.:,rrH-.l  „„i  uiil,  -,,.1,  |mi„.- 
tlkill^r  '■•■liv  ;i-   i-   III'.  Iv     I il.l,.   11,1,1,,,.  ,,||„.,.  ,.,„„|i,i,,|,. 


AL  TKRA  riONS   IN     IHK  CIRCl'LA TORY   ORGANS. 

'I'lh     ,1,;,,,^,   ,    i„    ||„.   ,.i,v,|L,|,,IV     n.o;,,,,,    ,..,„,.i:,||,     ,|„.   ,,,r,|i,„.    ,.|,.„,^,,,^ 

'"  ■"•III-  iMll.ii.Mi- .li-,  ,-,,  |,.,v,.  n,,  iiiU  l...„  -i„.ii,.,|,  ,-|„.,,;,|K  I,,  ,„, 
Mil.lrni-,  K,vl,l,  |;,„„l„,.,,.  :,nJ  l',-l,r,  „,i|,  -,„.|,  ,i^,„,,|  ,,,.„|,;  ,j,,„  ■, 
'"■'•"""-  •'  I'"""  'I'  il"'  mill"-'  iln|.M,-|.„„-,.  il,,,i  i„  f,„„,,  ,,,i,|,„,„, 
'""■  iii"'-l  ;i.-.|iiirrin.  Ill-  in  tlii-  ,lii,  ,ii,,ii  -|„,iil(|  !„■  |.  .|,,|  ]„  ;,  ,■;,,  ',,1 
'■^•i'iiiii'"i"ii  "'■  III'-  l"li:iM'.r  ..r  iIm  hrail  in  iv|,|,i|.  f.v,.,-.  'x,  ,;,i,|i.„- 
''''"^"'""  ■"I'l  '■'  '■'  II"   iii.ii-l-'l  ..It.  l;,li..n-   in   (|„.  Ii,.:,rt-iiin-,  I..  ..i,.,.  i„i,;,|K 

"'-'■'■^"'    '"    III'-   '-:i'l:i^'f   '-..■    iIm'    -cli I',lli,,|,.^i,.    An., I \  ,.  J,, 

•'!■"   ill"''-   '"-'-III- <-lini(:illN    Hirli   ,:n\\   Aiu\    mail.,, I    ,.|i;,.|,     ,f||„.  ,,,^1,,, 

""    •'";    'i'-''i-l.  ■ili'l    pr,,l,alilv  ,,n    lli,.   va- ■    ii..rv ,.-,  ,1,    ,„.,.„,.    j,,    ,;,,^ 

oilier   iiil((ii,jii-   c|l-«.,i-,-. 

The   PulSL-.--|-"i a   |,n.-li,.Mi,'  |M,ini  ,,(■   \i,.u,  tlMivloiv,  tli.-   ,-.,11- 

<liti..ii  ,,|-  III,.  |,iil-,.   f,.,„„    ,|„,  v.iA    l„.-i„„i,,^.    ,,,■  ,|„,    ,|j„,.,,,.    j,    ,^,,1,,.    .^^ 

''"I"'"'""  ^1-.  if  ii"l   !■'■-'  Ili.-Mi.  tlial    ,,(■  II,..    I,h,|M,-alnn.   ,„■   ,a,m    cf 

tlir    iiirv  ,iii~    -\  -.iiin. 

Kvni  ,liirin-  il,,.  inilial  m.i-v,  in  -•viav  and  m.-lnviirlv  -.■vnv  ra-,-. 
illKl  ilMialk  al-o  in  niild.r  ra-.-,  ll„.  |,„|-r  attain-  a  .^.n-ichraM,.  tiv- 
<|M.'n,.y,  ami  tlij.  ,,.■,•!,.•.  an..,n-  vi^.,r..n-  ynuvj;  mm  as  u,.|l  a-  am.mi: 
wnmcii    .mil    rl,il,|,,.|i    an, I   ,,|,i..r    imlis  i,|,iaU   (,.,„„,„,■,.    Fi._..  (i],. 

Ill    NMiniin    III,.    |,ii|M-i-at,.   all.r   lliiit\-H\    I, •-   ..li,.,,    narh,.,   ||i(. 

witl.  -li^^lii  miirnin-  ivini-H,,ii-,  u|,i,.j,  a.v  ir--.  m.irkr.l,  Imurv,,-.  than" 
'•"niiii"Ml.v    'Hviir-    in    t.v|,linii|  fev,-,'.       [„    ..liil.lrrn    tli,.  |„il„.-n,l,.  i-  ,.,,„. 

-i'lrralilv  lii...li,.r,  ,■,,,, I  rvm  in  \  hsumu^  x,,ii„      „  an  rvrnin-  |ml-.(-rato 

"I'  li'"ii  I  li>  I"  IL'O,  uiili  a  n„,rnin;r  th\\  u,  :mi  ,,r  |i)ii,  js  „1,„  .  ,.,|  .,,^ 
iMrl\   ,1-  ilic  ihini  ilav, 

in  -I'MT,.  ..a-..-.  ,.n,lin-  in  ,vr,,v,.rv  ||„.  ,,i,U..-rat,.  |H.rM>t-  at  tl„. -am,. 
Ii'idit    ilnriiit:    Hi.'    tii-t   u,,!.,  „itl,    rvm    -,„:,;!,.,•   ,lailv  nani-i,,,,-    ,|,.,„ 

"'■'■';  I"''--'"'  ■■''  "'-'•  ''~"='lly.  ■•II  III'-  '-ml  o|-,|„.  (1|.,,  ,v,.,.|<  an  a,|iliti„iial 
ii-i'  in  till'  Cri.iiniih.v   iM.|.|ir-. 

Kx._T|,t    in    ,.1-1-   Willi   a    viTv    l,..|,|    ,,n,^r,„„i,,  ,|„.  ,,,|nn„.  ,,„|    „,„. 

•"""    "'     ''"■    l"il-'   ■•II-''    ii-iially    - I    cln,.;,,..    ,|„,    ,1,.,,    „,,,|^         •r,iu.|n| 

•'"'  ''"'  "!■  Il"  ^^-■'■l^  til"  |iul-..  i-  likely  t„  lM.,.„ni,.  -„C,  an.l  mniv 
(•<>m[ii-|.--ili|i  . 

''''"■'"•'■'"■'''■"••''  "'■'''■'■''"'i^iii.-'" iiN-n    in    ty|,|„,i,M;.v,.r.   I   (1,„|    ,„ 

!h.  Iiy  n,,  mean-  l'n.,,ii,.n,,  ami  my  vsi^wunrr  in  tlii^  r,-],,,.!  a-nvs  uiih 
III.' '>l'-.Tvati,,„..,r,vliaM,.  author., (;,.i,..,|„^„,,.,M„,,.|,l^„„_^„„,,,j,^^.^,^^ 
It  wa-    ,„v-,.„t    in  .-,.!.   ,,..,•   ..,.nt.  ,.!'  all    ,nv  ,.,-,-.       Fn    m..,v   tl.an    hall' 


"S'> 


•V.'l 


TYriirs  I  i:\i:n. 


m 


k 
p 


(if  till'  (•:!-(■<  it  MiUK'nrcil  •'  niiiL;  tlic  li(ii:lii   of  ilu'  ili-ci-c  mihI    |Mi--i-ti(l 

lor    -,, till'    (ill!,.   ;      ill    till'    r'UKlilnIrr     it      lll-tnl    iMiIn      linllllW'!     Ill    lllIT!'    (I;l\  -, 

(irciirriiii;  ]i|'iii(i|  lally  iliirinu;-  tlir  iicrind  cit'  (ictirvc^c-ciici'.  1  iln  imt 
itiiU'IiiIm  r  ('\(r  tn  li.'ixr  .'Ii-itv  I  tiic  liliciioinciiuii  ('illur  diiriiiL;'  llir 
illitiMi    -I:ii;i'   111-    ilui'in;.'-   tln'    ti|--l    il;i\>    nf  tin     i',,'~t    Wirk. 

I-iiiNnir  the  MTiiMil  xM'i'k  ill  -lAi'Ti'  (MX'-,  cviii  ill  >iii  li  a-  iiiil  in 
nriiMTy,  till'   fatr    rontiiiiic-    IiIltIi    ami    tlu'    |iiiIm'    Iiituiih-    -iiiallii-   anil 

wrakcr.  .- ctiiiic.-  inlrrniittint,  sn  tliat  in  M.mo   ca-r-  lipi-  ila\--  il  ran  In' 

fi'lt  and  ciiiiiitcd  i>nly  witii  L^'i-at  ditlii-iilly.  Ali-rni-i'  of  tin' aprN-licat 
I'll  |ial[ialiiin,  incrca-c  lif  tlir  ana  of  cardiac  dnliic~~  to  the  riirlil  and 
lil'l.  and  niiitlicd  iicart— (iiind-,  |M.inl  to  acute  (lilatatimi  follow  iiitr  intcn-c 
intii'lioii-  clianirc-  in  tlic  invocardinin.  Marked  c\ano-i«  of  tlic  liicc, 
li;  id-.  a*nd  ii'ct  at  tlii-  time  i-  a  \iry  iint'a\oi-al)le  .-vin|iloiii.  It  occurs 
n-iially  in  alcoliolie-,  in  >ntVerei'-;  from  cln-onic  di-ea-e,  or  in  tlio-c  wlio 
lia\e  jii-t  recovered  from  -ome  ;ieiite  alVcction,  and  alnio-t  all  tlic 
patients  in  whom  it  i>  |ire>eiit  die.  However.  I  have  known  individ- 
iiaU  who  Were  well  iioiiri-lied  and  \  iiroroiis  to  recover  in  -|iit<'  of  this 
verv   L'raxe  s\iii|iloni. 

\\  lietiii'r  the  extreme  cardiac  w  !<ne-s  ha-  anv  eonnceiion  with  the 
jraiiL^reiic  of  the  tip  of  the  ao-c,  ears,  toes,  and  lintrers  wliicli  occurs  in 
si'M'fc  ca-cs  i-  an  intere-iini.''  .|iic-tion  that  still  remains  to  lie  solved. 
It  seems  |iri  lialile,  however,  that  the  piinrrenc  de|i<'iids  in  part  on  the 
s|iccific  chaiiires  in  the  vessel-wall,  \\ilh  thromliii— formation,  etc.,  con- 
dition- that  have  liecii  shown  to  play  a  part  in  the  procc.-  in  t\phoid 
fc\  er. 

A  retardalioii  of'  the  pnl-e-rate.  particnlarK'  a  low  pnlse-nite  in  jiro- 
portioii  to  the  icmperatiire.  whii'h  is  -o  charactci'i-iic  ol'  tvphoid  (i'ver 
in  pre\  ioiisly  hc.iltliy  yoim^r  nicn,  I  have  oli-crscd  oiilv  cxccptionallv  in 
typhus  ti'Vcr.  iinil  then  only  in  niild  ca-es.  It-  in'ciirrenci'  in  s(>\  ere 
eases  ((iriivsinircr)  I  liaxc  tie\  cr  oli-crved.  I)nriiii.''  the  period  ofdefci-- 
ve-ceiiee,  the  |iiil-e,  wliicli  in  -c\crc  ea-i's  ha-  lieeii  wiak  and  irrci^nlar, 
gradually  piin-  in  -IrciiLrtli,  and  the  piil-e-rate  lieirin-  to  diniiiii-h  (coin- 
|iare  l-'iL"-  fill.  If  the)-,,  ha-  Ijciii  laarknl  cardiac  w  ,  .ikiic—  w  ith  dila- 
t.'itioii.  th(>  pnl-e.  after  the  normal  or  -nlinormai  tempcraliirc  has  liccn 
reached,  contimie-  liiiweeii  SU  and  !hi  in  th.'  moiiiiin_r  and  reaches 
Hid    in    the  rvcniii;;-,   and    i-    c\ceidiiii;l\     iin-lead\  ,    -o    that   an\    trisial 

liodily  or   ni;'ntal    exciicincnt    1-    followed    liy   : ii-ideralile   teinporaiy 

accclii'ation. 

In  other  I'ases,  marked  liy  a  moderatclv  -e\crc  or  mild  course,  the 
piil-e-ivite  diinini-lie-  i,<i,-i  j,,(.«n  wiih  the  fill  in  tlic  lciii|M'raliirc.  the 
|)liy-iolonic   piil-e-rate  hciii;;   I'caehcd    within    iwcnty-fo.ir  or   ihir't-six 


■^VMI'TOMMdl.ocY. 


525 


It 


hour.   i„   ,.M.,..  ,.„,]i„^.  |,v  ,.,i.i,,  .,,,,1  |„  ,■.,„„  ,,|^,.,,  j^^  ,.^.^,  ^,,^^.^  .^_  ^|^^^^^_ 

A  r.M,.w,..l  ri-r  in  tlir   iml-.-n.i,   .Inriiiy:  tl...   [MTin,!  ,,r  •■.mvalrxT,,,.. 
<'.■<•■"■-    ,,nlv    in    tl.n-,.    M.v,.,-,.   ..a«.-   uiih    n.ark,   I    .aniiac    invulvrnnn. 
vvlH'n  tlio   I  ati.i.t   lias  l,.|t  iii-  I.,.!  I..,,  i.ariy  ;   or  i,  ..v.y  o.vur  a.  a  tnani- 
f.stati.m  n\-  >,,m..  .■nnipiicatin-  .•.m,lili,,n.       Tli,.  pufx-ratr  .inrin-  tl„. 

I»ri.«l   ,,(■  -•,,nvai...c,.n, .ra.ionali.v  t;,lls    to  l„.|ou-  ,1„.   normal.  aJ  low 

a>  of)  or  ts,  ;,n,l  inav  rrniain  at  that  point  for  In.in  ..iirlit  to  fonr- 
tr..n  .lay.-.  The  rause  of  tiii-  l.ra,ly,,.nlia  has  n..v..r  Iuh.,  ,,rop,,.K 
•xjilaincd.      It  also  <Kvurs  in  other  acute  infections  di-ease-— <li,,hthena 

tyj.hoi.l    ;i.v,r,  aral   .earh't  fever— an.l  ha> niin,,ns   -ijrnili.anee       I 

wa>  known  to  the  ol.Ier  authors  (IJarallier,  Kennedy.  .Mun^hi-on.  (irie- 
sinirer). 

The  State  of  the  Heart  and  Blood-vessels.— In  tvj.hns  as 

'"  ^>l '''  ♦■''^■•■'■>  ''"■  "'.v.K.inliti^  in  the  jrivat   niajoritv  of  cas.s  ap|„.ars 

to  under-o  eonipL.te  inv.,lnti,,n.  1  ,.aiu.ot  renieml„T  a  sintrle  case  in 
^vhieh  th.ie  n.n.  lined  any  cl.roni.^  insMliiei..nev  of  the  heart-muscle  if 
the  inte^nity  ,,f  the  oriran  was  cstal.iished  l.ey.md  a  douht  l.cforc  the 
l"'i:innin^'  of  the  disease. 

Th..  sune  is  true  of  valvular  l,.>ion-  which  neither  I  nor  anyone 
cl-e  has  ever  .,h>erved  as  -cpieU  of  lyphn.  fever.  We  niav  aceonl- 
iiifriy  nif.T  that  acute  endocarditis  nui-t  l,e  very  rare.  The  same  may 
I"'  said  of  peri.'arditi-.  I  never  found  any  inflammatorv  dep<,Mt~  or 
•■xiidates  at  the  autop-ic-,  and  o,dy  once  or  twice  licard'a  temuorarv 
pericarditie   friction. 

Of  the  eh  in-res  in  the  hlood-vcs.els.  the  arteric-.  and  v.in-,  l,„t 
li'.l"  I-  i^nowu.      As   in  all  a.MUe   infectious  di-,.ases,  the  period  of  con- 

valcMvu,-,.  from  typhu>  ieve-  is  marked  l.v  th asional  .Mrurrcnc,.  of 

so-callcl   marantic  throml.i   in   the  veins  opeciallv  in   ,l;c  veins  of  the 
'■iTs.       Phey    are    ,nost    fre.iuent    h.    p.aticnts    whose    vital    p.,wcrs    h.v,. 
'•<■«■"  sappe,!  I,y  want  or  ehroni<.  .lis,,,.,,,  a..d  in  ti.os,.  wh.,  |,av<.  snfr.n.l 
fr.iin   a   severe    fiinu   .,f  fvphus   fev.-r. 

Changes  in  tho  Blood.-The  stat.-  .,f  the  1.1 1  i„  fvphus  fev,.- 

;'•':  ' "  ••'■I'<'^"<"'b   ■••■f.MTcil  to  iu  th,.  se..ti.,n>  on  M.,rl,i.l  Anaton,v  an.l 

htioloifv. 

'I'l'o  n.e,,r.ls  l.c.|ueathed  to  us  l.v  fonn..r  ohscrv.a-  Im  r,..r-,r,l  to 
the.-olor  an.!  ..oa.irulal.ility  of  ,h,.  Id,..,.!  n..  lonirer  posses-  thc^i^nifi- 
"•'"«•'•  Mttr.:.ut..I  to  ■.h..n>  l.v  the  ..l.ler  authors.  Little  a-  w,.  "have 
'"an...d  l,y  Mi..ro-.opi,.  ...vamination  in  rcpu-.l  t.,  the  spe.ifie  ..an-,,  of 
th.'  d'^.'a-.'.  a  few  riual.l,.  ..l.s..rvations  have  !,....»  ,.l,taiu..,l  in  r,..ranl 
to  th,.   l,h..„l-....ri,us..i,.-.      Whil,,  th,  shap..  an,!   app,.aran....  of  ,h,.~r,.,! 


■"^  "^^  "j 


^--^  fill' 


'^-'  7)77/r.s  )-i:vi:ii 

(1  r,)ii^,l  ,.  j,  iiiKitl'cctcd  ill  the  main,  their  niinil)cr  is  diminislu'd  in 
wci'  ■  .arknl  <■:!-(■-  at  tlir  lici:.'lit  "*'  t!ic  ili~cu<c,  ami  tlic  aiuniia  jk  r-i-ts 
(Imiiiir  the  iriiMJ  ,,,'  rcMivali-iriicc.  ( 'iiri-(-|>()M(liii;_r  to  the  iiliL'''ifvtlirmia 
\\r  liml  a  riduclinii  h,  tin-  liciihiLrli'liiii  ilufiiii:  tiic  latter  (lavs  nf  tlie  (ii>t 
and  diiriiiL'-   the  sen-    I  u,-,  |<.       .\|,\    I'niind  llii-  rediictidii  to  he  fnun   jO 

tM    1  "i   per  eillt.    ill    ll    ca-e-  that    he  exaniilled. 

<  hi  the  other  hami,  the  \v  hite  lil.""|-ei||~  appear  to  he  in(rea>ed  in 
iiimiher  ((  (.iiihemalei.  Thi-.  appear-  to  he  a  -peeial  feature  of  the 
ili-ea-e.  and  it  atliird-  a  very  iniportaiit  aid  in  tlie  ditlerential  diaL:no~is 
from  typhoid  fever,  uhieh.  a-  i-well  known,  i-  marked  hv  a  diminu- 
tion rallier  than  iiy  an  inerea-e  in  the  iiiiiiiher  of"  the  iinkoev  te>. 

In  tho-c  ea-i-  ill  which  -.eriim  tests  have  lieeii  made,  it  has  heen 
h'lind.  as  wa-  to  he  expected,  that  till'  -eriim  ha-  no  ai:L;lntin.'ilinir  effect 
on  the  hacillii-  of'  {•■.ImiiIi.  This  tact  is  of  the  trnale-t  imiiortance  in 
tlilfereiitial    diauno>i>. 


1^   4 


;Mi'^^- 


W^m. 


THE    SPLEEN    AND    LYMPH-GLANDS. 

The  discrejianeies  in  the  statements  ot'  varioii-  aiitli<irs  in  re<'ard 
to  the -tale  of  the  spleen  in  ty|)lni-  fever  |iresent  a  marked  eontra-I  to 
the  uniformity  ot'  the  oii-erv.atioii  in  rcirard  to  the  oriran  in  tvphoid 
tl'Ver. 

While  a  few  aiitlior-  alliriii  that  the  -ph'en  is  alwavs  enlarirod,  others, 
as  (  )e-lerlen-I  )orpat  and  the  Kn;.dish  writers,  reiraril  splenic  enlar^romeiit 
as  rare,  or  (  veil  as  constantly  ahseiit,  in  ty|)hn-  fever.  The  want  of 
airreeineiit  oil  thi-  point  is  so  marked  that  it  cannot  he  altoirether 
(  xplained  liy  dillereiices  in  the  eiiaracter  ot'  the  di-ea-e  due  to  local 
conditions   or  to  ilitli  rent   jicriods   of  the  epidemic. 

Aeeordiiiir  to  my  own  experience,  eiihirtrement  of  the  spleen  e:in  lu> 
determined  f/iiiira/ii/  much  more  frei|neiitly  than  at  the  aiitops\-  tahic  in 
the  j:reat  niajoriiy  of  severe  ami  moderately  severe  cases  and  in  iiiaiiv 
milder  ones,  providin;j:  the  e.\-ainiiiation  can  he  made  earlv  eiionidi. 
'I"hi-  ditferenee  lietwceii  the  clinieiil  aP(|  anatomic  findinjrs  p,,ints  to  the 
main  reason  why  author-  tail  to  at'ree  ;  it  i-  that  they  made  their  exain- 
iii.atitiii-  at  (liil'ennit  -lap-  of  the  di-ease.  I  have  alway-  oliserved 
ciilarLrcment  of  the  sp|(.,.,i  very  early,  distinctly  earlier  than  in  tvphoid 
fcvi'i- — as  early  a-  diiriiiL:  the  iir-t  feiirile  days,  or  even  hel'ore  the 
Iteirinniiitr  "f  the  initial  stap'.  Fi  does  not,  as  a  rule,  persist  until  the 
iie^^riimiii^r  of  doferve-i'encc,  and  fir  that  rea-oii  ha-  ii-ii;illy  di-apiieared 
almost  completely  in  fatal  ca-os  hel'ore  the  sulij,..  t  come-  to  the  antopsv 
talil(\  III  -evend  in-tancps  where  tlie  ntpin  \va<  at  first  jHTceiitihlv 
cnlar.'cd    I  failed   to    make    it    out  with    certaintv  after  the  heL'inniiii'  or 


>Mi-l-ll.'  "f  ,1„.  H.,.,„„l  w.vk.      (■;,>...   in  wl,i,.|,  a  |,..,v,.,,til,l,.  ..nlar....M„nt 
|Mr-,,~i.  l,f.v.>M.l  III,.  |,..ri.«i  ,,r  ,|,.|;Tvr-,-,.ii,-,.  Miv  (liMinrtlv  r,-,,v. 

<><'-aMo,,,lly,,nMl,T,-oii,litiu„-ul„.,v  it  i.  al.-mt  tluTMrnt..  inf,.,- 

n-n-  cliMM-,.-,  sn..|,  a.  in  i.,.livi,luaU  uf  a,|va,„T,l  au.  an.l  .l.prav.l 
l-'lilv  .•nn.htiM,,.  I  liav,.  loun.l  no  ,,..|v..,,til,l,.  ..nlai-,.ni..nl  ,,f  tli.-  >,,|„.n 
•■I'li'i'  .-It  til.'  iM-innin-  ,,r  .Inrin-  thi.  ..ntiiv  .•,,nt--..  ,,f  i)„.  ,li„,.,„.  |„ 
.■xaMunin-  a  typln,-  tl-vrr  patient  fur  ..nla,-,.n,..n,  of  tl„.  -|,|,,,,",  ,|„. 
..nlv  nlial.l..  ni.i  l,u.|— palpatjon  —  j,  n.n,lr,v,|  M„n..wl,ai  ,lim,„li  l,v  ,|,.. 
•■"■I  'li.il  Ilir  ..niai-vrnrnt  raiviv  ,.xr,.r,|- a  nio.lrraf  .Icur,.,.,  and  tl,<.'ron- 
H~t..n,v  of  ,|„.  .„..,,>,  i-,  on  tl„.  avvrao..,  I,...  ,|,an  in  o.Ikt  inllvtion^ 
<liM.aM...  .S.n-n,v..n,.>,  of  ,!„.  nrj,.,n,  ulalluT  pa-iv,-  or  ..lirif,!  l,v 
pn--niv,  i-  coMiparaiivrlv  raiv. 

Aiann-  7(1  palirnts  a,hniltr,l  a.irin-  lii.  !!,>,  „,...k  „f  ,1,,.  .Ij.,,,,,.  wr 
tail,.,l  alt.Tly  lo  niakc  „„.  .■nlarir.aMenl  „f  tl,..  ^pK...„  |,v  nalpaiion  'aii.i 
'"•■"''■  ""t  a  .l.a.l.Itul  ..Mlaru'enuut  i,v  p.-naissioa  in  17,  uliil..  ia  \uv  n.n.ai,,- 
m;/  ••uses  tlu.  .•M  a,-,.MH.nt  ua.  a,a,i,.  on.  n.naily  l,...u....n  tl,..  tliir.i  an.l  tl,. 
<">  'l-'y.  In  tlu.  ,aM.  „f  a  uat-'lnaan  wl,o  l.a.i  l„...„Ma.  inn..,e.l  in  ,1,,. 
H..p.ta!.  a    a,-^..,  >,„t,  palpal,!..  .p|.,..n    was  ,„a.l,.  ,.nt   a.    ,i,e   ,i,st   .xa,„i     - 

-n,  n,n„...l,a,..ly  att.T  the   tifst  ..hill.      I    |,av..   n.v.T   l,a,l   ,1,. „,u„itv 

'.make  an  exannnat,,,,,  .Inrin,^  tl,..   p,.,-i„.|  „f  i,„.nl,ati„n.      It   is  pn.hai,!.. 
tliat   a   p„s,t,v,.   ivsiilt   uoiil.l   ,,ti,.n    !„•  ,,i,laii„..l   at   this  tin,... 

Tlu.  ...xt.n.al  ly,npl,-jrk,„,ls,  lik..  tl...  UH-vntww  an.l  l,fo,u.l,ial  ..Jan.K 
(«■<■  Mofi.t.l   Anat.in.v),  a.v.  >o  ti.r  as    I    ronl.l  ol,s,.,-v,-,  almost   Tluavs 

"ortnal  in  „t...on,pli,.at...i  ,.as,...      I„  ,  p,,,,  „,•  ^i,,,   1,,^,,,,,  ,,|,i,,,.,„i, ^;^ 

t".- mstan,...,  tl,..s..  .,f  ,|„.  (Vi,n,.an  war  ati.l  of  tl...  Hn-.ia„  ..atnpa.V,,' 
npnnst  tl,..  Tnfks_in(ia,n,„at.,fy  sw..|li„.  „f  tl„.  axillafv  an.l  son„.ti,„,., 
'.*  «1h.  t.t.trn.nal  lyntph-jriatuls  appears  t..  hav  I,.-..,,  '  so,n,.wl,at  tnoro 
'■'.""'I'M',  u.i.l   .K...asi.,nally    t.,   have  eii.le.l    in   snppnrati.a,. 

CHANGES  IN  THE  SKIN. 

Tlie  n..n.en..]atnr..  .,f  typhns  f,.ver  (typhn.  ,.xantl„.,nati..ns,  tvpln.s 
|.'t<-l"alts.  spott...!  iWry,  IMmms  ptat-p.,,,  ..pi.ien.i..a,  tnorl.ns  pnli,.afis 
M"..;."s  pnn..ti..nlaris.  fLhris  p..ti..„.a,-i~,  ..t...,'  sh.,ws  th,.  hnpottan...^ 
attfthnt,.,!  l.y  pl,ysi..ians  t.,  tl,..  ,hara..t..risti..  .•itanu-.s  of  ,!,..  skin  fr.„n 
the-  earl„.st  t..n,.s  wl,..„  typhns  was  ..onsi,!,.,-...!  a  snl,vari,.,v  ..t"  tvphoi.i 
f<'V..f,  to  the  pres,.nt,  when  it  is  r<v.,jr„iz„|  a-  a  .listin.'t  .lise;,^. 

The  Typhus  Exanthem._Th..  n.sh  is  in,l..,..l  s„ni..i,.ntlv  pe..,,- 
I';"-  "'  'I"  '"^'>'"''-  '.(•  its  app..aran..,.  an.!  .h.v..l„p,n,.nt.  it.  ..hafa..ter  a.t.l 
<l.Mf,l,„t,on.  to  l„.  ,.onnt...l  ant.-nj:  the  t;.w  spe,.iti..  an.l  .lia^nn.stieallv 
itnpoftant    |)h..n.in,(.na   .,f  tl,..  (Ii~..as(.. 

Th-  ,.n.pti.,n,as  w..  have  se..,,,  n..,st  fre.|,.ently  ap,H.ars  on  the  fonrth 

1110  -l»n,-onw>tioM. 


528 


ivriirs  ii.vr.n 


;<(-.:.;- 


m. 


-ri 


i^*^? 


(ir  lil'lli  il:i\   ■■t'  tile  (li-(a-i'.       Il   iiiiiy  a|i|"ai'  nil  tlic  -ixlli   i>v  MXriiih,  or 
a-  (■ai'l\    a-  I  lie  -i  ininl  <\a\  . 

I  lir  liiin' III'  a-  a|i|irarancc  \  al■lr^  in  liill'i  ri-iit  lipi  aliiic-  ami  in  ilill'cn-iit 
(■|ii'liinir>.  Ill  Uri'liii.  in  1>7^.  I  li'iuiii  llial  tin-  iiii|iii(in  a|i|)cart'ii  cai-K  — 
nil  I  1h-  xciiiiil,  ihir.i,  .i|-  |cMii-|li  ila\  :  «  lic|-i:i.-,  in  ihr  ciiidciiiii'  'if  ISTH,  llic 
(■ni|  linn  iifciirrcci  iiMiall\  laic  i'  nn  I  lu  rniirl  li.  titili.  ni  :i~  laU>  a- llic  >cvcnlli 
ila\.  I  .-111  |nin  a  laliic  tVnm  an  ani^lr  li\  riiv  a»i>laiil.  Salniunn.  In  ;;'.) 
ri!>,  -  iluriiiLMlin  r|:i(ii  iiiir  ni'  1^7!'.  u  I  Hi'c  •  1 1 II-  lime  nt'  a  1 1|  na  I'a  I  icr  cnnld  liu 
aiciiratclv  imtcd.  ii  was  Innnil  In  Ik-  a-  tiillnw- : 


li:i>   ..I   III.'  .li-rii.s. 

S.'.' 1  . 

■I'liini 
F-iinli  . 
l-'ilili  , 
Si\ili.     . 


(\1S.  -  n;i>   ,.f  III.'  .il-,  „>,.. 
i;  .^.■wiitli.     . 

4  Kiirliih    , 

II  Niiiili 

l;.  T.iiili      . 

0  Kl.v.i.tii    , 


1 

0 
1 

3!t 


MiircliiMiii  i'i\i>  ilir  liiinlli  clay  as  llic  avcraLTc  tiiiu' nt' a|i|n  aranro  nfihe 
iTii|itinii.  and  (•\|rc>,-l\  slalc-  llial  lie  raj-c-K'  >au  ii  appiar  later  than  llie 
titih  clay. 

('a>c>  in  which  tin-  irii|.|inii  i.- ri|«irn  d  in  jiave  liccn  dclavcd  milii  the 
iH'Ldiiiiini:  i^i'  lii<-  ^.i-niicl  week,  nr  cvin  until  tlii'  twelfth  nr  the  rnnrtccnth 
(lay.  iiiii>t  111'  acc'c|iu-d  with  L'nat  caniinii.  'rii:it  a  \itv  late  a|i]icaraiicc  i.s 
IKissihli'  i>  ].lci\|..|  liy  the  ca.-i  in  iiiir  taldc'.  liiat  was  distiiiL'iiisiiiMl  liv  the 
aiijicaranc  1-  '<{  the  r.oic  la  nii  ih.  i'IimmiiIi  day,  uitlmiit  |iic.-intini:  aiiv  nthir 
]>(M-uliaritv    in   llir  i-niiix-  nf  llic  cli.-cast-. 

With  il-  tir-t  a|i|icaranrn  ilir  ifii|ilic.ii  ccinu-  mit  all  at  (iticr  in  a 
-iiinlc  I  rc,]i.  -d  that  tlin  iihiinatn  extent  i-  ii-iiall\  cniniilctc  within  tiirt\- 
einlit  hniii'-.  It  is  wry  rare,  in  my  e\|iei'i(  nee,  tli.it  llie  diiratidii  nt' 
tlie  efii|iti'cii  la-t-  Iciii'jer  than  tlii-.  .\  -eeniMl  erii|),  nr  tli(^  ili-:i|i|)cai'aiiec 
lit'  the  eai'!ie-t  -|ict-  and  the  apjiearaiic'e  nt'  a  iie\v  trii[i,  i-  |)i'aetii'al!\- 
niikiKiwti,  and  \m'  tiiii-  liaxe  an  iiii|inrlaiit  di,ie|iii-tie  |iniiit  (lillei-eii- 
tiatiiiir   the    fn-ei.la    id'  t\|)iiii-    t'niin    tliat    of  ty|iiiiii(l    t'e\ir. 

Ill  feuani  tci  tile  to])iiirf:i|iliy  ol'  the  enipticiii,  the  ilr-t  -jint-  in  ca-e- 
that  I  \\;i-  ,ilile  to  iili-er\'e  tVniii  till'  l)ei::ilininn'  ilsiiallv  a|i|ieal'ed  mi  the 
jiiwir  .ilHliinieii  and  almiit  the  liaek  and  sluiiiiilers.  and  alnm-t  at  the 
same  time,  Imt  le--  thickly  at  fir-t,  the  sputs  appeareil  mi  the  clie-l  ami 
iipjier  alidmiiinal  iVLrimi.  \'i  r\  -nun  lliev  appear  nn  the  extreinitie-, 
wliile  llin-e*nii  the  triinlv  c dil iniie  tn  iiicrea-e  in  niiiiilx f.  Nni  ran  !\- 
tile  e.\tremitie-  ,are  cnNcied  at  the  -ame  liiiie  :i-  the  tninU.  (  )ll  tlw  fiire- 
arm-   tlie   sjint-    ii-nally  appear  lif-t  nn  the  tievm-  -iirt'ace-,  and  iiiiiueili- 

atel\-   ;it'ter\\al'd    ciii     thednr-al    -llfraee-.   dnwn     tn    ill'     ll.iek    nl'   the    liallll. 

<  )ii  the  len-  the  eni|  ti  HI  appear-  .1-  far  dn^vii  a-  the  d,ir-iini  c.f  the  limi, 
where  it  i-  nt'tcii  \  er\-  cmi-picaimi-.  In  t\pieal  ca-e-  the  eriiptimi  is 
lea-t    marked    mi    tl       tlii._;li.    e-peei.iliy    ..n    the   .anterit.i'    ■•irl'aci.. 

Tin-  di-triliiitimi  nl'  the   eniplinii    pre-eiil-  a  m.arked  ditlereiiee  (rmii 


MM//'yo.I/  |yo/.o(,  )-. 


.r2'.> 


that  .r„  in  lv|,!,„i.l    i;v,.r,  ul,..,v   ,i,..    ,■„..-,„„,    :,„,,„„,   |,.,,  , ^„„ 

''"■    '•"''"■'■   •'"■    I''"''    •"•'    I'' V(.|    tV,,in   Ih..  ininU.       K,,M.-|H,t.  ,„,  ,|„. 

t-ivani,^  in  i_N,,h,,i,l  an-  -,,    raiv   a-  i,,  l„.   ;,|,„,m  :,   rurioMlv.  and   I   |,av,. 
iKAir  Trn  llirni  a~  liir  <h,\\u  a-  (lie  doisnni  of  tlir  ll,,,!. 

'I'll.'  ta.-c  n-ualk  ,-,a|«.-..  , „•  at  Ica-t  i~  Imii  -|,arin;:lv  allark,,!  |,v  th, 
tv|.lin~  rniplinn.  A  liw  -|„,|-  n,ay  I,,.  Innncl  (.n  tlic  ti„',>  of  u,„n..|',  an.l 
'■l"l'livn  or  in,llxi,|,,aU  uiti,  )i,ir,  Im.l.i-  .Kin.  On  th,.  other  l,ah,|.  ll„. 
hi'v  i--alrno>i  alua.v-  tln-li,,!.  ,-|„  riallv  in  the  iM-iiniin-  an.l  i-  oft,.,, 
ili-lin.lly  clcnialon-. 

The   a-,.rlion    ,),„    ,|„.    ,,„|,   ,,,■  ,v,,|hi~  .litlir-  fro, at  of  tv,,lioi,| 

'" -'■'■^'"■''  ahnn,ian,vof  ,1„.   Ir^on.  i-  ,ni v  in  a  u.'n.ral  -,.,-,■. 

I'   i-.|Mil.'    trn,.    thai.  ,.x,-,.|,i    in    ..nain    ..,-.-    in  u  inri,    i|,..   ,.,nption   i- 

■'^"''""'^"■'>'  ^'' '^""  ""  'h"  n-unk.  ,l„.  , HTof  , .-,,,0,-  intv,,l,oi,| 

•■■v.'i-  .l.i.-  no,  ,„,,Hv  ..,|nal  that  ol,.,.v..,|  in  ,nanv  ,„-,-  ,,f  ,V,,Im,. 
"'"■•■'■  l""h  ,h,.  tnink  an,|  iho  ,.x,,-,.,ni.i,..  a,-,,  m,  ,|,i,.klv  .-ov,.,-,.,!  that  th,' 
"am,,  "-po,,,.,!  f.v,.,--  a,,,,,.,..  „,!„., ,,„i,,.|,  j,„,iii,|,i,,  (,„  ,|,eo,lar 
''^""'-  •'"■'■'■  ^"■'■,„,a  f,.u  ,a.-of  ,y,,|,n.  in  u  In,.),  ,|,.  ..,n|„io,.  i<  v.tv 
'"'"'>■    •''•^■'■l"l"'l    an.l    .■n,    l„.    f,nn,l    only  ali..-   a    .■a,vti,l    -,.a,v|,     anil 

'"■'"■'■'•'"'"-'■    '""   •■N"vn„.u,.  „„.,.,    ,    , „a-of  „,„|:„io„-.  I„„|,    ,, 

v<Vn:U    ,!„.    ,n,n,l„  r   :,n,l    ,|„.  ,liM|.il,nlion  of  ,1,,.  .,„,,.       Th,.,- ni    I.,. 

:"';'""'"    ""'    '■-'■-    '"-^'l-    'l-i.   in    analo,v  ,0   ,i,„il,,   ,,„„ii,i,„„ 

";th,.a,-n„.  ..vantluanata,  ,ni.l,t    I,..  ,|,.M„,a„.,|    a~    f.lns    ,.nn,tl,r //,.„ 

:""    ':'':''''^' ''■       ''■'"■^    "'"^'-    '"■"'■-'■••-    I-   .li-tinirn;.|,..,|    tVon,   .,,.,. 

";    ^^''"■'    ""•   '■'■"l'--^'-    "I'i"!'    '"av    l„.    ,;,i,.K    al.nn.lant.    i-    n,,|„„.lv 

"l-mv,l    l,y    .In-,,  |„^,n,.na,i.;,.  |,a,-aH,i,.    .rn,,,  i,,,,,.  -,,,,„.1,.,„„.|^,    ,,,; 
A-    ,v.a,-,U    tl,..,|,.v,.l,,,„nrn,    an,|    -|„.,.i,l   .JKMM.nT  of  ,|„.   ,,,,,„i,,n 

"""■'''^'""■'    -"-'-   '"^'>' l-'v,,l    in  a  fnlh   .i..v,.!o|u.,|   ,,,.,..     Tl„' 

stauvot  H,n,,l,.  I,y|„.,v,nia  ;    the-  Ma^v  ,ln,-in^.  w|,i,. n,o,-,-i,a..i,.  ,.|,.,n..v. 

'"■-'"•    ''"■  -'^'^""f  |M-,„ n,v.i  |„.„vl,ial  a|,|M.M-an,T. 

A  f.v^l,    ,v|,h;,-    i;.v,.r  -,.0,    a|,|-,.nv  n.  a  |,al,-,v,l  nia,.,!,..  ,-an,nn..  i„ 

T'  ";""  '''""'■^'  i''"-''"^"''""'=""''^'l-Mtil.  ran.K  la,-^,.,-.  whh^ill. 
■'<"-l'-'-..-,|'la„.  I..  Fi.  h.  win,.],,  a.  ,nay  l„.  I..„  .l,.,..,.,nin.li.v 
;"-'-->   ■;*    th-  ^la~,    |.l,.xi,„..r,.p,  ,lisa,.,„.a,-   ,.o„,,,|.,„lv  „„    ,,,,,,„,„,  ^,„i, 

.s  t  K.,.,.t,,,v  :„   li,.,t  of  a  pnn.ly  l.y,,,.,.,.,,,!,.  natn.v.      I„v ,j,  i,„Iivi.lnal. 

w.fh  „.n.|,.,.  -k,n  a  f..u   o,-  a  n,aJo,-i,y  of  tl„.   n,„,,i,„  ,;,.  „  ,i,„  ,,•  ,,„,^, 


"""""'■   '■ '"""'  "'  ""■  ■•"-■-i>'"~  "'■  'vphoi,!  (i.v,.,-.  wi,i,.i,  „;,. 

always   ,no,.,.   ,„•   I,...  |,a,„,la,-.  „,„!    ,,.,,!„  ,|,at  .•l,afa,.t,.,- a<  I ,.  ,!m,v 

:"■"'"■'''■'"'   ''"■   ^'■' ^    i"'iltrati,:„    in    tvpl.ns    li.v,.,-.  if  p.VM.nt   at   all 

.<   always    n,,,,.],    1,...    pn,,,.,,,,,,-..,!    ;„„l    v,.,-v    ,.va„,.s,.,.„t. 

''"'"■   '-'a..„la>-   „Mt„,.,.,  ,|„.   irn..:nla,-ity  an,|    in.listin,.tn,.s,  of  ti,.  .„,t- 
li.i.'s,  mul   ,!„.   pal,.  ,.o|o,-  of  tl.o  s[H.ts   ,.o„,l.i„..   ,0  ,nak,.  it  ,..x,.,.c.liM,.lv 

SI 


1 


ii. 


9'     " 


^^ 


^^i^^S'f' 


,>,■■■>,  .•' 


:*:    > . 


5:J0 


7177/rx  ii:vi:n. 


iliffiiiilt  til  ilrniiin-tititc  llii  (  iiiptiiiii  diiriiig  tlic  first  purely  Iivptn'iiiic 
.-t:i;^i'.  N\  liilf  a  -rarili  t'nr  iIh'  riiM'->|iiit~  »\\  dark  »kiiis  i-  jirarlicaliv 
liiHK>lc»,  it  i>  (lilliciilt  ill  an  any  iiim'  to  i(('ii).'ni/r  the  cnipliiiii  witli 
certainty  witlnnit  |irii|(er  illiiiiiinatiuii,  a  eireuni-taiice  tliat  iaii>e>  tlie 
jrreatest  trmilile  tn  lin-pital  re-idents  in  ailiniltiiiix  palieiils  (liirinj,^  tlie 
ni^'lit. 

( )eeasii)nall\ ,  tlie  enipii'in  >tainl>  mit  more  prniiiiiientiv  from  its  >iir- 
ronii(linjr>  vvlien  -een  at  a  -iiii:lit  di-tanee  tlian  at  <io>e  raiiiie. 

Ill  not  a  liw  ea-e>  tlie  eruption  does  not  develoji  Itevond  tlie  tirst 
liy|iereiiiie  -tasxe.  and,  al'ier  pei-i-tiiii,'-  tor  >everal  dav~  or  lonjjer,  dis- 
appear-   e pletely    without    leavilli;    tile    -iitrlitest     trace  on   tile  liodv  of 

tile  cou\  alcMcut,  or  oil  llie  cadaver  if  tlie  <'a.-e   lias  teriiiiiiale<l   t'atallv. 

Ill  tlie  ^rreat  majority  of  ca-es  tiic  ^illl|)le  liy|)ereiuic  staj^e  simiii 
pa.-x's  away,  and  tlie  ,-poi-  Income  darker,  of  a  coppery,  dirty-re<l  color, 
and  do  not  iri>ap|)ear  eoiii|)letel\'  mi  |ire-sure.  Iliev  liecoiiic  somewliat 
paler  when  the  plcximcter  i-  a|iplied,  lint  the  central  portion  still  pre- 
xiii-  a  dark-re<l  or  Mni-h  discolomiion.  due  to  a  de|iip-itioii  of  hlood- 
pijrmenl  (  I'late  !.,  1.').  Ihi-  de|io-ition  lie;jiii<  at  the  center  and  spreads 
to  the  jieripherv  .  so  that  the  spot-  -oiuetimes  cud  Ky  haviii^x  :i  livid, 
l)liiish-red  color  and  iinderj.foinu-  a  true  petechial  tnilist'ormation.  If  the 
.<pots  are  aliiindanl  and  widely  -eattei'ed  over  the  hody,  the  appearance- 
of  the  patient  liecomes  ali-oluteiy  repiiUi\e.  Sncli  <'ases  are,  Imwever, 
evceptiiiiial.  Ill  iiio-t  patient-  oiiK  a  lew  -pot-  undergo  |)etc<'liial  traiis- 
firmatioii.       The   eruption    pre-eiit-   such  variation-   in   the   niniiiier  of 

Icsinii-,  their  dcirri f  development,  and  the  di-trilmtion  over  the  liody, 

that  each  ca.-e  present-  a  ditfereiit  a]ipearani'e. 

In  irenoral.  it  niav  lie  -aid  that  the  lieiuorrhai;ic  -pots  are  mo-t 
numeroiis  mar  the  lai'tre  fold-  in  the  -kin — in  the  iiiLriiinal  retrions — 
and  on  the  dor-al  -urfices  of  the  Imdy  ;  heme,  these  rcirioii-  should  he 
c\aiiiiiied  with  particular  care  in  ca-e-  in  which  the  nature  of  the 
eruplioii    i-   doiilitl'iil. 

The  lo-c— pot-  that  have  iiiidcrL''iiiie  iiemorrhaLric  transformation 
iiiii-t  he  di-tiuLiiii-hcd  from  true  |ietechia'  in  the  strict  dermatoloixic 
-eiisc   of  the   v\oi-d.    for    the    latter   a]ipear    a-    liliii-li-nd    -pots    due    to 

direct    he rrhatre-   into  the  -kin,  and  are  not   ]ireeeiled  liy  a  hyperemic 

-tajre.  Such  true  petechia'  n-uallv  appear  ilurinjr  the  hei^rht  or  toward  the 
v\u\  of  the  development  ot'  the  ra-li.  They  arc,  however,  accordinir  to 
mv  ixpcrienec,  comparativelv  nire.  When  pre-eiil  in  -mall  mimliers, 
tliev   are   of  iio  .-ij:nir;raiiee.      When  they  ai'e  aiiimdaiit  the  pni^'iio-is  i- 

liad,   i-peciallv   when    tliev     ai mliined    with    extensive    heniorrhair<'< 

iiitii   the   >kin   and   siilieiitaiienus   tissue   and   evanosis  of  the   tiiee   and 


I 


1 


0 


DESCRIPTION  OF  PLATES. 


Pl.Alh    I. 
1.    H.-.VM.  .y|,!,u.  lever  „,ot»  of  no,  „.„,.  ,Iku,  ,w...U-,;,u.   l,..„v  ,,,,,j. 

.....  .nil  „,  :■:.  l.,,.,v,ai.  Htage  ;  .ak.n  f, „„.  „>„! ■  .  ,.,,„  ,  ™. 

^v..  y..ur.=a  age..unn«  a„  unu.ualiy  ..v.-.v  :u,:„  k   iV .U\cU   1...  ulti- 
mately re.overe.1.     The  ra.h  a,,,..red  ,.,.  th,-  tounh  dav  ,.,'  ,1.  .,i.,ea.. 

.f.h;Ji::i  •''™  '''■''■'■  ^""''' '"''*'•'''■      '^'-""^ '■'■■'-,;,.,;  dav 

Th,-   ,•„.....,„.,.  ,nv  ,.,„•  for  11,.^   nH«t   ,.,rt  of  a  dark  1m  id   i,u.,  a  l.w  of 
ti.eiu  ratluT  ,„„n-  .opiKT-olorfHl,  „wing  to  hen-.i-rlm^'it-  clmupe. 


Sm;..red   a,,,.,,,,,   .he    ro.e-.,,..„s  are  a  ^e^^    r.v.n.t   petechia.,  and   atone 
-I'-i    .a   ilu-  i,.^^,•r   ti-ht-liaiid  poriioti;  a  more  exten. 
rliMi'v. 


laupe 
echia 
isive  cutaneous  liemor- 


Pl   \  I'h    II. 
■•■.   Compar..   tai.  ui,l,    IMal.    I.      Ko«^  spot,   .ak.n   In.,,,  t!- .(,don,e„  nf 
a  «.,,„an  ihTtx..,,,..  v-.rs  of  a..-,  sollenn^;  ,Vo„.  I,/.!,,,!,!  fn-,,      Tw,  Itti,  d.v 

>!^1  Tl.'vTr i      '  ""  '  '"'"'""   ''^  ''"'"^  '"''''""■  "'"'  """"  ■"■  ""■  ''■^'  ""^  ^"■'^ 

'';;■.';'■'■     !';■■!'"■'> -A..,,    made   l,y  tl„.  aull„„    at   ih,-   ivd,id...  and    l,avt 
l>wii   laulitully  R-pro.luL'ed. 


IS--' 


i 


L 


'■  :^ 


>  1    f»     t 


fi 


■SYVI'InM  iliilnii  y. 


r,M 


' Miviniti.-.      I'litic'iii-.    ill  whom    ilii-    |.|i>  iionii  mmh    i-   prorni    ;i>   a  rule 

ITl-illl    M    I ilsill-      -|M-.|   K   I MI'.'OIIIII    ..(■    till'     ll.lMl'T||l:i-(  -     illlo     lllc 

'olijiiiHliv,.'    .111(1     tlic    .l:iiK,   livid     :i|i|Manitlir    cil     tllf    li.~.'--|H.t-.       Sll.'li 
pMliiiii^    lull    raicK     iciiiv  1  r. 

(  )c.a--iHiially,  .-|.c<i:ill\  in  airojioli,'  nial.-  in  iiiipaiinl  ](li\ -ical  luii- 
ilitiuii.  till'  ji^r,  ^111,1  (idixil  a-iMHt-  ipflli.'  Hvl  ail' iiivi  icj  with  iiiiiiicrniis 
|"l.vlna-,  cHcii|>\  iii^r  th.'  noi,,ii  ct'  the  hair-CoJlK  I.-  c,r  the  haii-tnlli.lfs 
lii'iii^cKc-.       I  hi^  |ihi'ii<<iiiriioii  ha-  iMi  iiinrc  |ifii;^ii,i-iic  -i^niilii  .incc  than 

tlic  cailin  til'  I lilioti  that  i-  at   the  hoitoni  .>('  it. 

It  i-i  a  ucll-kii'iwii  tjiil  ijiat,  in  liin,-  nf  <|.i(|(  niir,  pMiicnt^  -iitliriiij^ 
tioiii  any  (ihii).'  cunililidii  ami  |iiv-<ntin!.'  -inall,  ,ir(niii-<ril)c.|  cnta- 
li.'oii,  h.iniiiihap-,  |iM  iiiir  -kin  iiiilH.li,  |iiii|,iira,  tlca-hi.cs,  and  tin 
like,  havi'  Imi'ii  ric|ii(ntly  m  iil  I.,  ihc  |i,,-|,itaU  a>  lyi.liii-  Ctvcr  |iati<iit- 
l>y  |>liy-i(iaM-  c)|'  li,    \,-i\  (AIM  i-i(ii  «■. 

A-  in  (ithir  aciitr  i\aiitlicMiala,  i-|i(viaily  variola,  l.iit  not  wilii  thr 
-.aiiic  rii'.|iitii,y.  thr  a|)|Mai-anrc  ot'  thr  ciiiiPtioM  in  tv|.hii>    (<\(r  inav  Ix' 

:"'"'ii|''"''''''   "!■    i 'liat.lv    |.inrdrd     l,y    ;,    diHu-,.    macular,    purely 

hypi'icmic  iclii.-.- ot'  the  -kin,  (-p..i.i||y  on  tin-  Lack,  chr-t,  and  nrck. 
I  hi-^  phcnoini'iion  i-,  how.s  r.  very  rvaiK-.cni.  and  ii-iim1Iv  disippcars 
l>y  the  end  of  the  tir-i  day    .■    the  cniptioii. 

In  a  \'<\\  ca-i  .,  (-p,..i.ill\    in    [n'r-on-  with  a  -oft,  white   -kin,  I    have 

-ceil    the   true   eruption   a inpanied    or    immidiately    pieeclrd    l.v    th.' 

ap|>earaiiee  of  a  piviihar  laiL'-'  maeiil.ir.  ••  inea-ley  "  eruption,  .H-eiipv-""- 
eiiietly  the  t: iieann^  and  hack-  of  the  hand-;  tlii- .iiiptioii  rapi.llv  di- 
appeai-,  and  euntiniie-  t(    reeur  f.r  a  -hort  time  at  th<'  smie  plaee. 

'I'he  diinition  ..f  the  true  typliii-  eruption  .and  the  duration  uf  the 
iiidivirhial  >tai:.  -  a()pear  to  vary  in  the  ditreivnl  epideini,- and  to  some 
eMeiit  in  dilferent  individual-.  The  avei-,ii,re  duration  fir  severe  and 
moderately    -evere    eases    may    he    o;iv,.n    a-    from    -<.ven    to    ten    da\  -  ; 

traces    ..f    the    hei TliaLnc    eruption,    in    the    f.rm    of    palc-hrown    or 

t;ri4'iii-li-yellow  -pot-,  may.  however.  p,r-i-t  l,ey,,nd  tiiat  time  and 
cotitiniic   dnriiiir  coiivale-eencc. 

■|"lie    priin.iry.    piir,.|v    hypereiiiie    ro-e-sp,,t-    l.ist    a  vrv  short    time. 

"'■".'    ''='i'    ' I'lV"    lielnonhairie   dianire,   they  n-nally  disappear   oil 

the  li,-t  or  -,coiid.  or.  :,t  the  late-t,  on  the  third  day.  If  the  lienior- 
rha-ie  eiian-e  i-  ,,nlv  p.-rtial,  the  inacnlcs  may  u.,t  he  visil.h.  after  five 
"•r  -i\  da".  -. 

Like  many  other  phenomena  of  the  di-ea-e,  tlie  alMiiidance  and 
detrree  of  (leveiopmeiit  .if  the  eruption  depend,  ainoiifr  other  thiiijrs,  on 
tile  chara.'ter  of  the  epidemic.  In  -oine  epidemics,  aecnrdinir  to  relialile 
ailtiiors,  they  are  of  slijrht  extent  ;  whereas     ,.,  the  other  hand,  eiiideiilics 


mm^: 


,^=^^V^ 


o.-j-j  rvriirs  i  i:\i:i:. 

Iia\i'  l)f('n  ilfxTilx^l  tli;it  were  ili~tiiiLriii~linl  liv  tin'  miu~ii;il  iiliiiiidnticc 
Miiil  |iiciiiiiiirii'Ml  rli;if:icl(r  I  il  llic  i'IiImiicimi^  clmiip'^.  A^cilm'-  riol,  «(i 
liir  :i~  1  lia\f  ■pIimt\ cil,  a|p|Mar  In  alliil  tlir  aliiiinlain'c  i.t'  tlic  iiii|ilinii. 
( 'iiiitr,ii'\  l(>  tlic  r\|H  riciirr  lA'  Mun-lii-nii,  (  iii(--iiiii(  r,  I'.li-iiin,  I'x-r, 
and  \\  y~-,  I  liavc  -ccii  \\u-  ci-iiiiiiMii  (|iiiir  a-  |iiii|'ii-.r  in  dnlilrcn  a-  in 
ailult>,  anil    I'iialMW  '    a|>|)rai'-    ni    li:;\<'   uli-trv  cd    lli^'    -anic 

.IndiriiiL:  iVnin  invnwn  cxiMiii'mi',  llirif  appiai'^  to  Kr  no  ili-linct 
rclali'in  liclwccn  tlir  almndani'c  <it'  lljc  (rn]>lii'n  and  llir  -i\rrilv  nl'  the 
di-ca-r.  1  lia\i'-'i'n  tin'  nm-t  >c\tn'  tatal  ca-i-  \\illi  liltir  ur  no  crni)- 
tiim,  and.  CMnvii'-cU',  I  lia\c  lVci|Uiiillv  iili-crvcd  tlic  sinic  cniidiiidii  in 
\(i'v  mild  ca^i-.  I  am  will  auari'  that  I  am  i  vafiainT  in  tlii-'  \  irw 
witli  that  III'  M  ni-i'lii-iin.  (  ifii---iii;:iT.  and  maiiv  i.l'  tlir  nidcf  aiitlinis 
(  l!a-iiri,  I  Irndcr-nii.  and    Stnarl  |. 

In  addilinn  1m  thr -|iicilir  c-liaiiLTi-  -"  tat' dc-ri'ilicd.  tin  I'l  ai'r  man\ 
ntliif  I'litanciMi-  |ilntiiiinriia  that  di'-ri'\c  ni'tiii. 

AniMi'.:.--  ilic  ni'Ti'  iin|i"nant  i-  the  a|i|icafanrc  nf  miliaria  crystal- 
lina  in  till'  middir  III-  at  I  In-  cud  ut'  tin-  -mmd  wii  k.  I'fum  unr  t..  three 
da\--  lietiife  the  liei.'innin_  nt' i|e|er\  <'-eenee.  I'lie  eni|itiiin  i-  "I'll  II  Ver\ 
aliiindant  mi  the  elie-i  and  aliduiiien.  and  i~  mufe  ('n  ipi'  hi  \  niineei'  than 
in  iildir  indi\idnaU,  ran  l\  neriirrini:'  alter  the  |iM'l\  ..I'th  >ear.  The 
euntiilt-  lit'  the  \-e-lele-  in  all  the  e:i-e-  e\aniilled  li\  me  \w  I'e  aeii'  .r 
iieiitial  ill  iH'aeiiiin,  iie\  er  alkaline. 

I  iil)-er\-ed  mili.ifi.i  er\-talliiia  in  alinndanee  in  Irum  li  |Mi-eeiit.  tn 
S  lief  eeiif.  Ill'  iii\  ea~e-  ill  the  \ear-  i>7~^  :ind  1^7'.'.  <  M  hi  r  antlnir- 
ui\e  a  iiiiieh  liiuhef  |i(  reenta;:e.  while  ,M nfelii-mi.  mi  theniher  hand, 
-late-    that    t  III     -\  niptmii    i-    fare. 

\\  Ili'lleVer   lhe\     Were   Well   deSeli  •[  led .    the   -lldamllia    \i  ere    tiill.iWed    li\ 

di-tiiiet  liran,  \  ile-i|namat  inn  "I  the  -kin.  'I'hi-  de-i|namatiiin.  Imu- 
evcr,  i>   willimil    dniilit    a     \  er\     emnmnii    i  n  >  iirreiiee   during    llie    |iiriiid 

111'    eiinvale-eenee.     and     t'lillnW-     I  he       -|>eeilie        ,v  ill-eni  |  it  ic  ill     a-      ,\ell      a- 

miliaria  er\ -lallin.a.  It  alVeel-  the  entire  -kin.  inehidinL:'  -neli  |Mirtiiin- 
a-  were  iinl  eii\ered  li\  the  rii-eiilnii-  eril|ilimi — a-,  till'  in-Iallee.  (lie  iiiee. 
Ill  '1  ea-o  diiriiiLr  emn  ale-eeiiee  !  -aw  a  -hediliiisi'  nl  the  e|iidcriiii-  ill 
JaPire  -I'ale-.  -neh  a-  are  ii-iiall\    -eeii  in  -earlel  I'lAer. 

riien  i- a  marked  \;irialimi  in  the  -tateineiit- nf  dillireiit  antlmr-  in 
reirard  til  the  iieeuri'eiice  of  herpes  facialis.  .Iaei|iiiit  -aw  it  iiiiiiK- 
til'tliiif  hi-  |>atieiit-.  while  in  (ithcr  e|)idemies  it  wa-  allii;.;('tliel' .ili-eiit 
I  !  lertnailll,     I'eter-liMfy,      I>^7  1-7")).  I     lielievc    the    ali-eliee    iil      lier|)('- 

fiieiali-  til  li      Aee|itiiiiial  •   it    i-  certainly    liiirly    t'rei|neiit — iiiiicli   nini 
ireijiicnt  lliaii  in  t\|ilii.id  t'cvci-.      In    ix7!l  lier|M>  liniali-  ^\a^  prc-i  lit  in 

'    \'.'ili  sHii'ji  II  iilii-i   ih--il'-  liil<-/.ti<.iisl,riiii/,/iiitr>i  nil  Knidrsiilli  r.    Uioii,    IS'.lT. 


sYMrr'iM.iToi.om . 


'.i  |i('r  cent.  i.C  oiir  p;ili(Mi«,  ^iikI  mure  Irccjiiciitly  diiriiijr  tlic  Ixtiiniiiii^ 

III     llic  cli~c;iT  tliaii   (llll'iliL;    lllr  |)(ri(>.i  nj'  lirt'crvc-i'clicc. 

Ill  .1  nmnlirr  of  i-m-o,  iliiriiiL:  llic  -rcnid  wrck  of  tin-  di-iM^r,  I  -:i\v 
;i  niiiilcrMlcly  -cvcic  icterus,  v\illioiil    iii;irkci|    change    in    llic   I'nlur   i,\' 

ill"   -IikpI-.      Thr-c  r-.-iM-  wci-c  all  \i  r\    ;jra\c,  ami    -I    ni'  ihcm  (  I  uiit 

"f  til  tiiiiiinalcd  t'atally.  At  llic  aiitii|)-ir~  ii<i  rliaiiL!!'-  wiTc  timinl  in  the 
larger  L;all-|ia~-air'-  nr  in  llii-  duodi'imni.  Iiiil  \  crv  r.iarUiHJ  cKnidv  -\mII- 
iiiLT  wa-  |in-ciii  in  tlic  li\ci-. 

Cutaneous  abscess   ami  furuncles  aiv  nut    rir(|U<ni.     'riicv 

Were    |iri-(iit    in    a    liw    ca-c-,  mn-    nm-i    almndant    nn    llic    iiali>,  and 

'"■i"i-i d    c'ln-idcralili'  annciyaiiii'  to  tlic    |iali(iit  dnriiip'  I'lnvaif^cciicc, 

wliic  h    \\a-    |ir(i|on'^cd    nn    aciMinil    nt'  tlirir    |pr(-cnci'. 

Bed-sores   -nit-iA  in  a  litlli    umi-  ;;  |i|.r  ci-iu.  n\'  ni\-  ("I--I-.       \)\  — 

|■^L^•ll•dillL' ca-i^  llial  \miv  mmli  |iiuti-artc<l  liv  (■(ini|)licaliiiii>  and  -r<|iicl., 
the  <'iiiiilitiMn  mcimiitii]  diirint;'  llir  tnic  (•diir-c  ot'  tlir  di-ca-c  unlv  in  \irv 
-r\crc  ca-c-,  Irnt  in  tli.-c  tlic  -m-o  a|i|icarcd  -o  ra|>idl\-  and  wcic  -o 
c\tin-ivc   a^   tip    "iiiiuc-l    :i    -cvciv    ti-n]iliic    di-tni-i>aii<-c    in    additimi     ti. 

'I -iliiian    |.r<--iirc-r.tVcci-.     ()c(a-ii)nall\ ,  tlicy   were   c(iniliinc<l  with 

al>s>c--(-  aiKJ   dcc|)   nlcirati.>M~   IcrinininL:-   the   -niiciitaiicdii*  (■ciiiilar 

li^-iic,  or  cvcii  imin>  (n-  |<~-  extensive  cxtliliation  of  nccTutic  Ukuc, 
inviilvinu-    the    -acnnii    ami    cnccyx    and    c\cn    the    -eapnia'. 

In  vcfv  -<vere  caM-,  especially  wliefc  there  had  lie-ii   iii:irke<l  iieinnr- 

rliauie  ehaiiLie-    in   the   cn;ptii.ii,  -lin-ht    im-ulariti.'s    in    the   l.eddin- 

wrinkles    in   the   -lied-,  etc. iith.-ed  t(p  pr.MJiiee  iilni-h-hlack  -pot-  aiMJ 

stripes  on  the  -kin  of  the  hack  and  liiittoek-  in  a  verv  sh,„t  time,  and 
these   often    llirnieil    tiii'    inicleiis   ot'  e\ten-ive    pnndent    li  — ne-iieeresi>. 

(ian-rine  may  he  oh-civdj  in  tyjihiis  i'rv,  r  in  certain  portions  of  the 
-km  lint  e\iio-ed  to  pi'c— lire,  hill  far  rmiox.'d  tVoni  the  center  of  eircuia- 
tioii.  |",,r  ohvion-  rea-ons  this  doe-  not  occur  in  the  -evere-t  C.rins.  Thus, 
I    have    seen    irantrrene   of  the    tip  of  the    iio-e   and    ear,  and    verv    fre- 

<|mntly  of  lli,^   ski serin-   the  toes.       An  entire  toe  may  lurro-e  and 

necc-itate  cNartlciilatinii.  Seli;.,.r  oh-erved  uan-fciie  of  the  tiiievr-. 
I   my-elf  havciicvd-   -,.,.ii    it,  and    other  authors    note    it    a-  ;i  em  io-itv.  • 

Erysipelas,  which  in  the  older  wriiino-  i-  mentioned  a-  a  freipient 
complication  of  i\pliii-  liver,  ha-  heroine  verv  rare,  owm-  to  the  favoi- 
ahle  c,.iidiii,,ii~  jircNailin::  in  modern  ho-pital-. 

Noma  and  hospital  gangrene,  wlii.h  are  al-o  memionnl  in  the 
iilcraliire,  are  of  no  nioiv  than  a  hi-toric  inten-t  at  the  pre-ent  da\. 

Cciti'iii  ivliahle  oh-,a'ver-iMiirehi-oii,  I  a'nd.  ( Jerhard)  proli— to  have 
ii">i'''l  ^i  pi'iiliar  odd-  from  the  -kin  of  tyjilin-  ti  \  er  patient-,  a-  in  the 
<'a-e  of  the  other  aeiit.     iid"e.tioii>  di-,.a-es,  espeei.aliy  tile  exanthemata. 


i 


-x:i  jiA^^^ 


:.w-' 


-t-OT; 


''-^m^dMmSi^^mM-m^m'm 


fffifii 


■);U 


ryriiis  i  i:vr.n. 


'I'lii'  imIiit  is  (!(>cril)c(l  as  mu-ty  ur  as  "  iiioiisiv,"  ami  is  said  t" 
Ixciiiiic  \cry  iiiai'kcd  when  llic  |iali(iit~  aii'  rIci-cK  cniwdcil  :  llii-  i- 
i|ilitc  to  lie  i'\|pc(Ic(l.  Wlii'tiicr  it  \s:i-  (jiic  |m  ihr  taultlrs-  vciit  ilat  inn 
1  caiiiiiit  -ay,  luit  I  nr\cr  iiiiti<'(ii  any  -|i((i(ic  i  \lialatioii  lV(.iii  (.iii' 
]>atit'iit>    in    tlic    Miialiit    la/aitttd. 


if'-':*: 


THE   NERVOUS   SYSTEM   AND   ORGANS   OF   SPEQAL   SENSE. 

Di-lurl  aiicc- (if  the  iicrvnii.--  sy.-tciji  aii'  \  <  ry  marked  fimn  tlic  licjriti- 
iiiiii:,  and  later  ihey  t'diin  liii'  |il'ediiniinant  fealiire  in  llie  clinical  |iielni'e. 
'I'liey  ai'e  s<i  eiins|)iciiiins  that  typlin-,  a-  well  a-  tvplmid.  tevci-  wa-, 
until  al'tef  the  middle  ot'  llie  eiL;liteentli  I'llitniv.  idenlitied  with  "nerve- 
tc.  ef,  '  111- at  least  fci^arded  a-  onent'  it-  snli\  ai'i<'tie-.  i'.xeeiit  in  xcrv 
inihl  cases  of  shnrt  diifatiun,  the  syin|itiini-  icfei-alile  t.i  the  iiei'Miiis 
system  diii'in^''  the  entife  ti'lifile  |]ei'i(id.  and  in  -cNd'e  ca-e-  during'  llii' 
convahscent  |ieiii)d  as  well,  ai'e  tlir  mure  mafked  and  jieisi-tent  than 
ill   any  nther  aciit<'    iid'ectiims   disea-e,  not    exceptiiitr   t\|)lioid    le\er. 

The  clinical  plienoineiia  do  not  iii  the  least  lalU  with  the  offrauic 
cliailjres  fiiillid  in  the  centl-al  iiel'Vdn-  system  l)\  oUf  |i|-esent  method- 
ot"  rcs(ai-cii.  These  |(heiiomena  ai'e,  without  a  doulit,  due  luticli  more  to 
the  effect  of  the  toxin  than  to  the  rise  in  tem|ieiatufe  itscH",  as  was 
flil'iuerly  l)elii'Ve<i,  since,  iiotw  itli-tandin^  a  fa|)id  ri-e  duriiiu'  the  lieyin- 
liiujr  of  the  disease,  there  ai'e  no  cori-cs|iondinti:  nervous  |ihenoineiai 
at  this  period,  (^iiite  often  they  :.re  u'o  -e\er<'  dur!ii>r  and  after  the 
jieriod    ot'    detirveseeiK c,    :iiid   any    e\|Miienced    |)raetitioner    will     recall 

cases  in  which  the  t<'m|icr;iture  rcmaiue<l  low  throuLd t.and,  uexcrth'- 

less,  there  was  marked  delirium  or  coma-vijiil. 

Ill  severe  and  miKlentely  sc\  (  re  eases,  the  ]iatients  com|)lain.  on  the 
Very  first  <lay,  of  such  ^I'cat  la-situde  ami  pneral  |irostr.ition  that  thev 
imine<liately  jr"  to  lied.  None  liiu  the  \-cry  mildest  cases,  and  these 
only  exceptionally,  remain  amhulalory  cases  throti;rli()Ut  their  entire 
fourse. 

Headache.  —  .Mmost  all  the  patients  in  the  iK'^rinnitifr  complain 
of    lieada<'he,    which    per-ists    throuiihoiii    the    initial    period    until    the 

:ip|M'ar:uii f  the   ni-li,  and   oiteu    lieeonies   so    inten-e  as   to  mask   all 

the  other  symptom-.  The  pain  is  refericd  to  the  m  ite\,  frontal  rcdoii, 
eyes,  and,  in  a  few  eases,  tn  the  <pceipui,  radialiiij:  down  into  the  ik  ek 
iind  shouldi'r-.  ('omhined  with  the  headache  there  are  freiiiientlv  pre-- 
eiit  vertiiTo.  pain  in  the  s.ici'um  and  linili-,  ami  h\  pere-thesia  of  tlie 
tiriLTcr-tips,  toes,  ^md  soles  ot'  the  ti'ct,  which  rnan\  patient-  finil  partic- 
ularly di-tre— iuiT. 

Psychic  Disturbances. — Duriiijj;  the  (ir.-t  dav  there  is  little  or 


sy.Mi'niM.iTDlnr.Y. 


h',M 


no  (listiirltiin 


<l    Irll 


I 


(•('  lit   (•i)ii-cicni<n(> 
lal'i^ic,  :ili(l,  Mitlinil; 


('Mil   ill   "cvcrc  cases  ;   tlii 
~tl 


|iati('iil>  an 
Ii 


|-(-tl(>-,  lie  -II] II  tluir  hacks. 

spite  nt'  tlic  trivat  |irii-tratioii  imi-i  dl'  tlje  paliciit-  canimt  -lei'p  day  ui- 
liiirht  ;  it'  tliey  do  tail  a-lecp,  tlicy  are  iiiiiiiediately  miixd  t'nuii  tjieir 
siiiiiilicr-  Ky  tenityiiiL:  dicaiii-.  'I"lic>e  eoiisist  >niiictiines  in  peculiar 
sonsitiuii-  reeiirrin^r  again  and  again,  sneli  a.s  a  >eusatii>n  as  ot'  snaring, 
tlyiiig,  or  falling. 

.\t  till-  peiiiHJ  the  mental  (aeiiltie-,  even  in  tliese  verv  severe  case-, 
are  -till  well  piv-crvcd.  .Mtlioiigli  tliey  are  dull  and  disinelined  to 
any  mental  nr  hudily  activity,  tlie  paiiciit>  -till  retain  clmseiullsne^^  ut' 
their  siirriiimdings.  When  -pnkcii  t<>,  they  aii-wcr  -hiwlv  ami  in  limken 
jihra-c-,  lint,  on  the  whole,  correctly.  They  evidently,  however,  experi- 
ence snine  dillienlty  in  collin'tiiig  their  thought.-.,  cannot  rcadilv  conii  e- 
liend  long  and  complicated  ipie'>tioii<,  and  when  they  atteni|it  to  do  -o, 
their  attention  -(mhi  wanders,  their  thoughts  drit't  into  other  channels, 
or  they  later  complain  ot'a  marked  inerea>e  of  the  pain  in  the  lie-ad  and 
oyes. 

Toward  evening  and  chiiing  tlu'  night  divmns  and  hallucinations 
continue  to  haunt  them.  c\en  though  lliev  are  awake.  A  lew  are 
violently   delirious,   e\('n   at   this  early   period. 

It  is  <inly  in  the  milder  ea-"-,  however,  and  in  nioderatelv  >evere 
cases  of  very  short  duration,  tiiat  the  |).-y<'hic  <li.-tiirl)ances  are  con(ini'<l 
to  these  narrow  limit-  throngiioiit  the  course  of  the  di.sease.  During  the 
second  half  <if  the  tirst  week  most  jiatiints  liecome  more  and  more  stupid 
and  eonfusetl  even  during  the  day.  .Vs  their  mental  e<iiidition  hecomes 
worse,  the  snbji't'tive  symptou's,  es|H'cially  the  headaclie  and  backache, 
subside,  and  by  the  end  of  the  tirst  or  the  beginning  of  the  wcond  wit-k 
loss  of  eonsciousness  is  usually  eomi.icte  and  permanent.  With  eves 
half-shut,  com|)letely  cut  otf  from  the  external  world,  the  patient  lies 
either  niotioidess  in  be<l,  sunk  in  a  diH'j)  a|)atiiy  and  muttering  to  him- 
self and  picking  ;it  the  bed-clotiies  with  trembling  hands,  or  el.-e 
gesticiilMtes   wildly   and   crie-  out    in   his  terror. 

The  patient's  behavi.ir  during  tlii-  stage  dc|»eud,-  on  various  external 
cireuinstances  and  on  Individ, lal  temperament.  In  some  |)atients  depres- 
^ion  is  most  prominent,  in  others  delirium,  making  its  app(-aninee  in  the 
evening  and  lasting  the  entire  night,  sometimes  persisting  in  thedaytimo. 
In  vigorous  young  individual-  the  delirium  often  partakes  of  the  nature 
ot  violent  mania.  They  mtre  and  cry  out,  jump  out  of  IxhI,  ami  try  to 
esfa|)e  from  their  terriiyiiig  hallucinations.  Smietimes  they  beeomo 
intensely  aggressive  and  try  to  injure  their  attei. .Lints,  or  tliev  eiidangiT 
their  own   lives  by  endeavoring   to  ecape  through    the  window,  etc. 


0 


¥ 

.1 

k: 

■Wi!'- 


536 


Tvriirs  I  i:vi:n. 


Suicidal  ;ilt(|ii|il-,  -iilil.'  witli  (li-:i-trull-  n-lllt,  li:iVi'  •.\\~i<  ImtII  .iK-rr\  r<l. 
'I  li"-'-  "li"  "<!■''  ill  :iii  ilri|iaiiv.l  -l:il(  <•[  licnilli  lictlirc  tlir  lir-iiiiiiiiu  "f 
llic  (li-c:i>c   ami    old    :iii<|  ,|,viv|)it    |i:ili(iil-    |iri'-<iil  a  (|iii(ti  r.  iimrc  riiiil- 

tci-iiiL'-   t'lii-Mi  ..r  (Iclii'iiiiii    IV ihr  \rry   l>.i:iiiiiii]i;  and  dnriiiL:  llic  ciilirc 

lilililc    -la-r. 

Ill  iiin-i  ca-i-  llic  ilrlii'iiiiii  i-  l)a-id  'III  :iiir  or  iiK.T-c  tMiiiiriii-  liallil- 
•■iii:ili"ii- ;  ill  Mill,!--,  iliciv  i-  a  Mi'ilalilc  tli-lil  i,l'  iilia-,  ivdii,ii|M  ,|ii> 
I'li'ii'iil  '"  'li''  \i  r-i'  >'f  (Aliaii-ti..!!.  Til,  dclii-ion-  aiv  ii-iiall\  of  a  -;id- 
diiiiiiL;.  cl(|ir,  — lii^.  or   a-italiii-    nalinv — ilclii-ioii-   of  death    or   di-ca-c 

aHiriiiiM    friend--  or  r<  laii\,-.  of  |iei-i'ein  ion  |    |ier-onal  daiiLier.  -onie- 

tilne-  niidei-  ill,'  iuo~|  reinnrkalili  eonilil  ion-.  -i|e|i  a-  iK  iiii:  in  a  liallooii, 
cr    lii'iiiL:-    in    an    o|m  i;    lioal    on    llii'    lii-|i    -ea-.  eli'.       In    otli,r  ea-e-   ilic 

lialliieiiialion-    aiv   , eted    willi    person-    or   olijiei-    in    iIm'    |Kilieiil'> 

iniiiiediat,'  \  ieinitv .  'I'lie-e  lialliieiiKil ion-  max  a--iinie  the  nio-i  |-inta-tic 
Jiiid  !iTril\  iiii:  form-,  or,  what  -eeiii-  to  me  more  fi'e(|iieiit,  the\  mav 
ivler  lo  tiifiner  event-  in  the  )ial  ieiil"-  lili,  to  hi-  oeenjiatinii,  to  -nmc 
tixed  haliit,  or  lo  hi-  \  iei-  and  |ki  — ion-.  In  a  eoii-idefaMe  niimlier  of 
ca-e-  the  eoiiditioii,  a-  i-  ijiiite  lr(i|i,  atlv  ipfovcil  i)\-  the  lii-tor\,  i-  a 
."iiniile   exaeerlialioii    ,.i'  fehrile  aiKJ    alcoholic   dihi-ioii-. 

.\  lai'ce  ward  full  of  t\|p|iii>  fe\<'r  |ialiint<  otfer-  the  ureate-t  iiiia"-- 
iliahle  conlra^t-,  and  the  confii>ion  ari-iiii:  fioiii  tin-  wild  nudlev  nl' 
tc\cri-h  ^roaii-  ind  dellri..n-  ra\iiin-  i-  eii,,ii^h  to  -jiake  the  iicrvc-  of 
tile  -leai'iie-t  |)iiy-iciaii  ;  it  lia~  lic<ii  known  to  M-atter  the  le>s  I'oiioiisi- 
l)le  attendant-  in  |iaiiic— Irickeii  tliLiht. 

Aim. 1-1    everv    author   tell.-  of  |.e(  nliar   and   often  verv  reniarkahie    hiil- 

lilciiialion.-.       MurcliiMni.    HildeiiliraiHJ,    I    (iiiiKiiii    de'   .Miis>v    ilcMrihcij 

their  nun  ver\  iiilerestinL'  I'.-yciiic  coiiililion,-  a>  they  reeallcf  iheiii  after 
recovery.      One  u|'  in\    |.ati(■lll^,  a  la\\\er.  ot    a   natuially  \i\a(ioii>  leiii|,era- 

llicnt.  exiiiliiti'il  .iin-iirj    the  lexer  -o  \  iehnl  : litipallix    to\\;ird    hi.-   atleiid- 

aiit  that  the  Miaii'~  lite  \\a-  in  daiiL'ir.  .\liir  hi>  recoxcrv  he  reineini  ered 
di>lincily  the  deiaiU  of  the  teiril'xinu  a|i|.arii  ion.  and  do'-ril  ed  Imx^  ih,.  ],iaii 

^oiiielime.-  a|i|.i  ared  to    lia\eeii,ir >ly  |o||m    aiiii>aiid    Icl'-  o|-  eUe  inlhiled 

him-elf  to  iVi-lilful  |.ro|„H-iiui;-,  or  -at  >  In.-  hed  uillidiii  anv  hea.l.  Tlie 
a|i|parilion  xva-  ,-o  IriLjhtfiil  at  oi,e  linie  a-  lo  indue,'  hini  l,,  all.ark  the 
inoii-t,a-  with  a  knite,  a>  In-  liiiii>,'lt'  atlerw  ai  d  niniiulMr,  ,1.  Anelli.r  one 
"f  'ii\  |iati,nt.-,  an  o|.|  -ailoi-.  iiiL-iiiiiii'il  hi,ii-,  If  lor  ,la\,-  t,,^,.|||,.r  i,,  ;i 
,a-,n\'-ii' -I    ,li.riiiu    a    \  ioleiii    -lorni.    -iirr.Mnnl,,!    hy    hn-e   iilack    hiil.-.       In 

'"■'iii.^     |i,aticnt>    ih,     J    dlii,iiial!,.ii>    ,ai,'   ,\c,','ili!ii:  f.     i otoiHiii-    ami    r,  |  ,  .it 

tlieiiis,'lve-  il.av  aft,  r  ,i,-i\.  W,-  had  a  >ci-,-,,r-- riiidn-  in  ih,-  war,|  ulio  for 
day.-  a  1 1, 1  ,|a\>  uould   r,'p,  al.    ■  II.ix,'  \  ,■  aiix ;  hiiiLT  lo  l  i  ind  ',•  "  and  a  caelaiiaii 

who  «a.-   ,,Milinuall\    iiiLiiii-   ,,ii  h;-  li.ir-,'s  an,!    |ouii,i   -tant  ,„-,ii|  aliou  in 

|-e|iairiiij    hi-  I'vi.K'hl  ly  inn,li  dila|.l,lale,l  \,hi,'le.       .\  |..,i  h,,-  of  in\    lalieiil.-. 

"ho   afnr    hi-    ,  ,■,  ,,^  .i  v    l  ,ii  i;,-.l   m    !.,■   a    ,lerk\\iiii    ii\  ,-t,iii-  teii,li  im-Ji's 

■il'duixin  t,>  onani-iii.  iiii.-i'jiii,d  liini-.  If  ,lea,|  an,!  1  raii-lale,l  t,,lhe  lii-hcr 
^clii■■ll^.  \x  hence  he  , -,1111, 1    hi.ik  ,io\\n  ,iii  his  ,|ead    hoiiy  ami  uitlle.■^.-  the  prcjv 


,'    I 


^"^i« 


-     i*4^a*^ 


s)MrniM.\'rni. <,'!)■. 


637 


aralioiis  for  liis  .,hii  fiin.Til,  f)iiii,!L'  lliin  linif  lie  hiv  iti  :i  iimtUriiiff 
-lilirimn  iill.riiMliiii.'  uilli  cMtiiltiilic  ri-i'lilv.  Delusion.-"  of  ilfalli  and  of 
hciMi:    liurii-.i    :ilivc    liavi-   ;iIhi    li.cri   (IixtIIkmI    I)\    nilu  r   aiilhur-. 

'Ill' -'I   ••mil    iliirilioii  (,(■  iIjc   (|(lii-i,,u-    Ma'^c.  lik.     ihc   cxinv— Imis 

lit    llic    lirliriiiiii    it-rir,    aiv.    i>t'  <■ --I',  -iilijci't    In    iiiaiiv  \;iriatioM-.       In 

(■iiiii|>aralivrlv  rare  ca-r-,  a-  we  liavr  -n  ii,  tlic  ilcliriiiin  ajipear-  (liii'liii: 
tlir  lir-l  ilay-  nt'  tin-  ili-.'a-r.  aii'i  in  -ui-li  i-a-i-  llic  |ii'ni.'nu-i-  i-  liail.  I 
l-cim  iiilitT  line  i-:i-c  in  uln'rli,  wirli  a  ia|>ii|  ri-c  ..I'  iiin|irratuiT,  I'Mrii.ii- 
•  li'liriinii  iln-laiv.l  iiM'lf  l.cliMv  tlir  i ml  of  t \vriil\ -linn'  Ik.iii--;  tlii-  ra-i' 
ciiili'il   I'itallv  uii  ijic  i'i;;lilli  .lav. 

Milcii    nil. IV    I'lv.jninllv  ilir    ililirinni    a|p|irar-    lair    in    tin-  iniilijlc  m- 

sc.'i.ikI    lialf  I.!'  the  -k I    w, ■,■],,  ,,r    ii    may  in    raiv   raM-.  a-   uli-rrvcl 

iiii.v  III-  twir,.  Iiy  invM  If.  lie  ilrlaycil  until  a  .lay  c.r  wu,  lnt'inv  the  licLriii- 
iiiiil:  i.t'  lift;  rvc~(TiiiT.  .\-  a  rnlr,  the  iv-ili— ni-  ivarlic-  il>  liiM'li,-t 
<ic,i;iv,.  towanl  tlir  cikI  nf  llir  lir-i  ,.r  tlir  lii-inniiiL'  nl'  the  Mvcml  \vci'l<. 
-Mil  r  th.ii  till'  |)alirnl~  linoinr  i|iiictir,  tin-  iii-oiunia,  wliicli  up  to  thi- 
tiiiio  hail  h.rn  alinu-t  I'nii-lanl.  liirin-  t><  yiiiil,  ,in<i  ,,nc  i.f  ihr  iii,,-t 
ticliirlitrni  cvriit-  at  t!ii-  lime,  in.liratiiitr  a  niark.il  rliaiijrc  I'm-  tlio  l.i  tt.  r, 
i.s  a  Iiiiil;  anil  I'i'stt'nl  >lii|). 

Otiicr  patitiit-,  auaiii.  wlio  aiv  Mitl'i  riiiir  t'rnni  a  very  >cvcro  form  of 
tho  iliMa-c.  Io~o  their  ie-tle-iie>>  only  to  -ink  into  .le<.j)  and  'astinir 
eoiiia,  whieh  in  the  frreat  inajofity  of  ea-e.-;  en. Is  in  deatli  after  a  few 
da.\>  or  sorii.tiin.s  even  aftir  t w.iity-f.nir  hours,  iiut  whi.'ii,  after  |>.m'- 
si-tinj:  several  .lays,  may  .11. 1  in  r.v.ivery ,  as  I  myself  have  seen  in 
several   eas.'s. 

Coma. — 'I'll.'  f  )rm  .if  -tii|>.)r  known  as  .'..ma-viiril  is  .if  the  worst 
])..-sil,i,.  |,r..M||,,.|ie  sii.|iili;.aiie,..  The  patient  is  pal.',  evan..ti.',  with 
liai:irar.l  lealiiiv-  .an. I  li.mirinir  .jaw,  eye-  wi.le  .ip.u  ami  starinir  iiit.i 
.'pa.M-     usually,    h.'    is    al.-.ijiitely    impervi.piis    t.,    .•xt.runl    iiiHiienees, 

•'''' i^l'   >"iii.'tiiiie-    ih.^   -en-..riuin    is    ,,idy  inodrr.it.'K    inv.ilv.-d.      'I'h.. 

ext.Tnal  -kin  i-  .•,„,|  an. I  .'.a.-i.'.!  with  a  e.,1.1  p.  r-pir:ition,  wliil.^  tlu' 
!■  inp..raliire  in  tli.'  r.vtinii  may  I,,'  -ui.n..rmal  ..r  .a.ii  iMirile.  The 
extivmiti.-  are  i<  y  .•.,|.|  an. I  r\an..ti.',  tli.'  -kill  r,,\,r\ui:  the  t..es  am! 
lin-.r-  ..ft. .11  i-  «rinkl...l.  anil  tii..  linii,-  aiv  eith.T  fl.N.HJ  aii.l  n,.,tion- 
l.'.- ..r  111  a  .-oii-taiit  tivm..r  iv-,.M,!)lini:  -uli-nltii-  leii.liniim  with  ear- 
lili..|.i-y.  Th.'  tivnh.r  -.muiim.'s  iv.-i.Ji.-  -..  int.  n-.' a  .le-r.v  as  ainio-t 
to  warrant  K.in- .vill..,!  a  .■..iivni-i  ,.  \\|„.ili..r  the  e<l..ma  ..f  th.'  pia 
f"m.l  at  Ih.'  aui..p-y  ha-  anylhiim-  1..  .1..  with  it  i- ,•,  ,|u.-ti..n  tli.at  is 
slill  ..|H.|.  f.r  iiivesti-:,ti,,n.  A.I.I  I,,  this  that  tli.^  iv-piraii,,.,-^  f,.r  days 
may  he  invi-il.l...  that  tl,,.  p,,!-..  .aniiol  l„.  IM,,  aii.l  th.it  tli..  h.^art- 
s..uiids  are  haivly  aii.lil.j..,  and    it    .an    ivadily  he   uii,!ersto.«l,  esinvially 


^j!?:^:::^  V^^h:^.    -.•i,Si^jt 


:,:;,s 


ryriirs  ii:\i:i{. 


m^% 


if  th"  cxtrciiiilic-  arc  free  fnim  trniinr.  tliat  tlic  tran-ition  fri>m  -iicli 
very  fiiiiit  iii:iMilt>tatii«ti>  of  lite  to  actual  dcatli  uftcii  dccurs  alinor-t 
im|)(n  ('])iili|\ . 

Sensory  Disturbances. — For  ol)vioii~  na.-on,  l.ut  little  is  known 
riVanlitiL'  tlic  <li~nii-li;iiri(-  of'  -nisiiioii  during'  tlic  ili-caM',  (■.-[itcialiv 
(luring'  tile   trlirilc  -taijv. 

'I  lie  ili-tr(~-iiij_^  .--yiiiptoin-  of  tlic  fir-t  >taj:r.  ~iicli  a-  |iaiii>  in  tiio 
lofs,  fitipT.-,  and  tlii-ii~.  radiatinLT  i"  tlic  |)o[ilit(al  .-|U(v,  wliiili  siih.-idc 
diiriiii:  tlic  prrioil  of  ~in|ior  and  coma,  olicn  rcajipcar  as  consciousiicss 
1-  i-c-c~ial)li-lir(l,  ami  roniiniu'  to  annoy  many  |)atiint-  np  to  tlic  time 
of  convalescence. 

Severe  nciiralL'ic  Main-  in  certain  ncr\ c-tracts  occa.-ioiially  a|i|)iar 
durin-  the  time  ot' defei-vc-ceiicc.  'riie~e  nenral;;ic  j)ain~  are  (|iiitc  com- 
mon, i)nt  fortunately  -uliside  .after  a  eoni|)aratively  short  time  without 
any  s])ecial  treatment.  'i"he  nerves  of  tlie  lower  exiremitio,  espeeiallv 
those  of  the  I'cct  and  toe-,  are  attacked  with  predilection  ;  hut  I  have 
al-o  known  the  sciatic  nerve  to  he  aifceted.  The  distrihutioii  of  the 
hnichial  plexus  i-  more  rarely  attaeko<l.  Whether  or  not  it  is  a  mere 
accident  I  am  uualile  to  say,  hut  as  reir.irds  the  tri<:cmimis,  I  .saw  only 
supra-oiliital  iieuraliria,  and  hut  i;  eases  of  that,  in  mv  t>.\periencc  in 
-Moahit   in    ls7s  and    l.sTit. 

Anesthesia  eoiiline(|  to  ap|)roximate]y  the  same  regions  as  tlio  neti- 
ralLMa,  thouixh  more  rare,  has  hceii  ohscrved  al-o.  The  attacks  of  anes- 
thesia are  likely  to  la-t  lonjrer  than  tho>c  of  ncuralfria.  I  have  luiown 
ane.-tlie-ia  of  .in  area  on  the  iliiirh  as  larjre  as  the  jialm  of  the  hand  to 
persi-t  for  three  months  after  recovery,  and  a  similar  one  in  the  dis- 
trihutioii of  the  ulnar  nerve  to  p.-r-i-t  two  months  after  reeoverv. 

Motor  Disturbances. — .\mon<r  pn.  nd  motor  (li.sturhances  we 
may  nientioii  a  more  ..r  le—  extensive  tremor,  which  is  almost  alw.avs 
jircseut  at   the  heinrht   of  the  disc.-ise   in   severe  tmd    modcratelv  severe 

eases.      Most  free |i lent ly,  it    i-   ( lined  to   the  forearms  and    hands;   at 

other  times  it  affects  the  trunk  and  the  four  extremities  ecjiiallv,  and 
in  such  a  .lejrrcc  as  to  suirj;(-t  to  the  oliserver  genuine  convulsive  or 
choreic  contraction-,  and  tlii-  may  possilily  account  for  the  fact  that 
some  authors  have  r(>|)orted  ireiieral  convulsions  and  St.  Vitus'  dance 
as  oee:isional  complications  of  typhus  fever.  It  is  worth  notiiifr  ih.,t 
any  external  motion  when  the  patient  is  conscious  or  semiconscious,  or 
any  <'han>re  in  the  delu-ii,u  when  the  patient  is  comatose,  is  followed 
hy  marked  jiirjrravatioii  of  the  tremor,  jii-t  a-  in  the  ca.se  of  a  true 
Intel    iou-tr(>inor. 

Ill  many  patients  the  mu-cular  unrest  assumes  the  character  ol'  sub- 


SYMI'T<iMAT()I.()(;Y. 


539 


sultiis  triuliiiuiii  with  carplioloyry.  All  ih,-^-  ciiiviil-ivc  pin  tionirria  an- 
iiiiicli  more  coiimioii  and  iiiuri'  violent  dmiiii:  the  liciirlu  uf  a  tviiliii.- 
f'cvcr  attack   liiaii   tlicv  arc   in   typlmid   (ever. 

Tnic  j^cncnd  anil  partial  cc.iu  iil-idns  arc  coinparalivciv  rare  If 
they  oc<  iir  at  all.  tlicy  do  so  in  yonn^%  cxcitaMc  indi\  idual.-  or  in  alco- 
iiolic-,  usually  in  the  middle  or  toward  the  end  of  the  sec.md  week  of 
the  disease,  an<l  they  arc,  as  a  rule,  of  had  proirnosiic  si;::iilicanc. .  The 
patients  may  |ia-s  .luay  in  a  convid-i\f  attack  or  they  mav  live  for  a 
few  ilay-  ath'rward,  dnrin;.'  which  they  remani  in  dei'p  coma,  with  or 
withont  a  return  of  ih.  convulsion-.  Alllioiinh  these  attacks  prc-ent 
the  jrcncral  jtidnre  ot'  cclainp-ia,  and  arc  often  aecompaniiMi  l.v  alliu- 
miiniria  and  ne|.hritis,  it  has  not  as  yei  l.eeti  satisfactorily  .Iciermiiicd 
whether  they  are  to  he  reirirded  as  nremi<'  in  charjieter.  I  havi'  seen 
violent  convulsions  in  2  eases,  one  of  which  was  eiitirelv  free  t'roni 
nibiiminiiria,  and  the  other  showed  hut  very  small  amounts  of  alhmniii 
in   the  iiriiic. 

Partial  convulsions  are  distinctly  more  niiv.  1'he  hest  niarke<l  case 
that  I  have  seen  was  one  in  a  writer,  nineteen  years  of  afre,  in  whom 
the  eoiivtilsions  were  ct)nfined  to  the  rijrht  lower  half  of  the  face  and 
the  rifrht  upper  arm  ;  this  ease  terminated   favoralilv. 

Tetamis  and  conditions  resemhlinjr  trismus  are  iKvasionallv  men- 
tioned in  the  literature.  Tliey  have  not  come  mider  mv  ])crsonal 
observation. 

On  the  other  hand,  I  have  seen  t»nic  eontnietures  in  individual  nuis- 
cle  groups,  as,  for  instance,  in  the  flexors  of  the  forearm,  keepiiif;  the 
hand  eonviilsively  eienche<l  for  days  at  a  time,  and  once  in  the  form  of 
obstinate  eontraetion  of  the  left  biceps,  causing  forced  flexiim  of  the  fore- 
arm on  the  arm. 

A  few  of  the  j)atients  under  my  observation  were  much  deprcsscnl 
dnrinfT  their  pori.Kl  of  eonvalesoenee  by  repeated  daily  attacks  of  painful 
eram|s  in  various  muscles  and  muscle  groups  following  sudden  move- 
ments in  these  parts.  The  museles  chiefly  affecttHl  were  those  of  the 
calf  of  the  leg,  individual  muscles  of  the  back  and  alnlomc  ii,  and  the 
muscles  of  the  forearm.  One  patient  woidd  be  attackcnl  by  cramps  in 
various  parts  of  the  Ixnly  at  the  same  time,  following  such  slight  move- 
ments that  fi.r  days  together  he  did  not  dare  to  move.  These  cramps 
had  no  progno-tic  significance  nnd  disa]>pcare<l  after  the  patient  rec.vercd. 
I>i-tinct  catali'ptic  condition-^,  which  for  eonvcnieiice  are  reternyl  to 
at  this  jxiint,  are  not  fropicnt,  although  a  more  or  less  pronounced 
tendency  to  cataleptic  rigidity  is  not  at  all  nire.  It  has  Ix-en  ol)serve<i 
chiefly   during   the   height   or   in    vhc  second    half  of  the   febrile  sfeige, 


^^\       ■«■"-"? 


a^?^|5?^/^r^^i^\-| 


r.io 


ryriit  s  i  ivru 


'^■/ 


niiii\   i:iiliri.  :iiiii    i-  ii-ii:iii\   a—iM'i.iic.i  u  iili    ~i  ii|"ir  ni- i'c,iii:i-\  i^rjl.       .\s 

ill'  -<■   '■ lilii'H-   .il'lrll    ln;ikr    lllf   ilillicil    |iirllll-c   :i|>|l(';||'    lliucll   W.ir-i'    tll.ili 

il    i-,  il   i-   iiii|M,ii:iiil    li.r  ilic  |ii-aitili r  |..  !„•<■(. iiii'   i li(,niii;;lilv  lainiliMr 

w  illi    iIk'Iii. 

I':il-ii~  f,  liralilc-  III  aiiatoiiiii'  altiral  ii  m-  aiT  y:\vi- — (■•■rtaiiiK  iml  tiinrc 
'■"iiiiiiiiii  tliaii  in  i\|.liiiii|  I'lVir  III-  in  -iiiall-|i.i\  anil  ulliii-  arulc  ixan- 
llirniala. 

Hemiplegia    lia-    Ikih    .li-rrilicd    iti   varii.n-    ciiidcniii-  i(  ; a  iir. 

":"ii|"'"i-      * 'ii''  <"i-r  lit"  ilir  kiml  \\a-  i,li~i  rvi'il    a n;j  iKir  |.aliini-  in 

'II''    'I'l'l'inic    III'    ls7!i.       Tiny    a|i|Hai-    I..    I.r    ili|Mnilrnl.  a-    ~liii\\n    liv 

~ ■  "'    'II''    anlii|i-ir-.  iin    licnii  Trliai;!-     inln  llir    nimi         -  nv    intn    llic 

-nl.-lanii'  III'  till'    In-ain,   niniT    i-arcly  uri  inilmli- r    i  linnnlin-i-   nt    llir 

l.ir^iT  arli'i-ii-  nl'ihr  rcnlinini.  ami  llani{ii'ln  (Ic-ci-iiinl  (iMf  ca-i-  nf 
tlinmilii.-i-   III'  ihr    li  fi    niiijijli'   cri-rlual    ar|ir\. 

A— niiatcMl  w  itii  lln-r  I liiiiin-  wr  liml  |ial-ii-  .if  -in:;lr  rMi'crnil  ics 

ciiniliniiil  iiftcn  witli  cji-inrjianr.-  i,|'  -cnsitiun — am-ilir-ia.  |pan-ili(-ia. 
ttr.      (/tie  ,a-r   III'  pariial    |iai-;il_v-i-.   i.t'  tlic  cniii'c  li-hi    Ic^- (ilnrin-  ilir 

(■|iiil.nii.'  lit'    \X~iX),  uliii-h  at  lir-t  \va-  i iliincil  wilh    li\  |icn>tlic>ia  anil 

latiTuitli    tlinnicati and    uliicli   diirinir  tlic    |p(iiiid  i.f  coMvali-rcncr 

drv(li.|ird  inio  a  uril-niarkcd  niiini.|Mi;:ia,   1  a w    incline*!  In  riirard 

a-  a  niiirili-,  a-  1  ,lnd.  I.y  nil  iiiicc  U\  my  nntc-,  thai  it  \va~  later  tiil- 
liiwed  liy  |.i-(.niiiiiieed    inn~enlar  ati-ii|(liy.       It  wmild  lie  Iputli    intefolin^r 

ami  |)riitita!ile  In  cNaniine  hy  rnudern  niethnd-  -ncli  ea-e-  uf  i i(.|ileu'iii 

in  tntiire  i'|iidenue-,  to  >ee  uliellicr  tlie   ina'ioiitv  ai'e  imi  due  til  iiein'itis. 

Meningitis.  —  Intlainiiiatinn   of  the  icrel.ral    and  -|iinal    ineniiiMe< 
<MM-ni~  with  varying''    t'fei|neney  in    the   ditlereiit    j»ri(id~   aii<l   e|tidernies. 

'1  he  nio-t    e\|)eiieneed  |)hy~ieiaii>  (  Miirc'hiMin,   I'eai k.  .1.  niicr,  .Iai|n(pt. 

IJaial'iei')  al)~(ihilely  deny  the  neeiiri'enee  ul'  ineiiiniriti-  in  l\  |)hii~  liver. 
Miieriiii:  '  al-n,  dm-inL'-  the  ( 'riineaii  e|)ideini  •,  ua-  iinalde  to  di-eovcr 
any  inllaniinatiMn  or  .-niiiim-atinn  in  the  nieninire~  nt'  2n<>  easo,  e\eii 
thiiiiirh  a  eai-efnl  niiefii-e.,|iii'  e\ai  linaliuii  \\a>  made.  llaiii|ieln,  iii'Vef- 
thele— ,  i-e|iiiri-   I  t-ital  ea-e-  nl'  |iui-nl(  nt  nieiiiiiMiii-  1,111  (if  a  mial  "if  ~rl*\ 

jialielll-   in   the  epidemie  ul'    li'iLTa. 

DISTURBANCES  OF    THE    SPECIAL    SENSES. 
Eye  Disturbances.— The  eyi -,a-  «>■  ha\e  -een,  aivahimM  alwavs 
iiiMiKeil  III  a  -lijlit  dei:rei',  tlie!-r  bei'  -■ ;!  marked  iiijeeiiiin  and  an  inerea-i-d 

"■'■I'"'! I'  'III'  '■■'njiiiieiiva',     Thi-i      I  ill  net  i\  a  I  catarrh,  u  hieh  \  erv  iniich 

r. -eiiiM.  -  thai  which  inciir-  in  niea-ie-.  in  - ■  in-iaiici-  a|i|iear--  dnriiii.' 

the  -taire  "I'  inciihaliiin,  a^-uciated  will r\/:i.       With  the  l)C"iiinin«>-  of 

'  (^u-fil  l.\    Miir.  lii-..ii. 


sYMrni.M.woi.oi;)- 


541 


till'  f'llirilc  imtIikI  in  ilic  i;r<':it  iiiMJcirilv  of  .ax*  ilic  .Mlurrli  l«<r.)riu>  ><> 
lii:irl<(c|  :i-  III  lie  ..I  iij|i-ii|cr.ili|i' cliau^Md-lir  iiii|Miilaiii  c,  -iiici'  ilii-  -taLTf 
|ir(~ini-.  -d  little  I  1-1  lliat  i-  ihaiai  icii-tir.  In  -i\  itc  .  a-< -,  in  w  liiili  llic 
|(aliiiil~    licwitli   iM-   ■i|i(ii  111   |iair-<i|«ii   ami    ihr  iiiiiiiiiirti\  al    filliA    i> 

wry  iiiarli\i',  tin'   i litimi    imt    fairl\    Irail-  In  tlic  rnriiialiipii  uf  -ii|»i- 

(icial  i-iiniial  iiliii-.  i"ln-  (lii|«f  laMf-  ul'tlii'  cortira  but  fafcK  liccniiif 
(ii^casi'il,  altliiiiiL;li  I  \\:i\f  iiiv-ilt'  -nn  mir  ca^r  ut'  (•xlcii>ivc  paii'iuliN - 
liialiiii-  kifatiti-,  ami  in  \ciy  -i  viir  i|iii|(iiiii~  iii-tamt>  liavc  linn 
n'lMirtid  111'  ncrfiitir  kifatiti-  uitli  ]it ftiiialiuii  ul'  tlic  ruiiua.  anil  i\cii 
pami|(litlialiniti-,  nm. litimi-  that,  t'i)i-tnnatrl\ .  diil  iml  miiif  in  aiiv  ul' 
inyiax'-.  I'lit-c  lunilitiun-  a|i|><ai'  In  lir  rnnHniil  tu  tiirrii- ut' tlic  ili-ca-c 
in  uliii-li  riiina-\  iirii  i-*  a  |ir-i.tninrnt  I'tatnif. 

IIciniiri-liai.'r-  into  tin-  rnnjiinrtiviL'  air  i|uitc  cunn in  -ivcrr  ra.-cs, 

e-|MTiai!y  in  ali-i.lmlir  -niiji'i-t-.  When  bntli  t_vi-  aiv  alliTtiil  am!  tlif 
111  imiirliai:r  i-  i\tcn-i\  f,  tlic  [latii'iit's  a|(|Har-anrr  i-  ali-uliitiK  nnramiv, 
ilitllim;,r|,    the    |)fiiii'--    i-    lit'   mi    sprcial    -i^niliianrr    tu    the    (Vf    it-cit". 

I'" ruin  till' l)f^ri,iiiiii^  ill"  tlic  tli-ia-i'  the  |iii|iil-;  |.ii-.nt  mithiiiL'  cliar- 
actcri^tic.  Imt  later,  c-|)iiial|y  in  -c\eie  ea-e-.  tlics  .it'tcii  Imiiiiiic  iiiaik- 
edly  ciiiitraetiil,  ami  when  the  euniraetiuii  i-i  extreme,  the  appearance 
ot'  the  face  in  per-mi-  u  ith  lii,r|it-ciiliifc<|  iriile-  lie.umc- (|iiite  peculiar. 
IIiiw  thi-  piieniiineniin  i-  prniliiecil  i-  rmt  kimwii,  altlimiirli,  (iii\  imislv,  it 
caiiiMit  lie  the  i-e-iilt  III'  acciilcnt. 

Ill  ii'_Mri|  to  the  chaiiiTc-  ul'  the  rct'raclivc  iiicilia  anil  uf  the  eve- 
priiiinii,  \vc  have  very  little  ilcllnitc  kmiwleilirc.  It  i-  true  that  we  timl 
niciitiiiii  III  the  iicciiireiice  111'  \itreiiii-  opaeitic-,  chdruiiliiis,  iriti-.  ami 
(>|itic  nerve  atniphy  in  -pceial  tcNt-hiiuk-,  Imt  in  tlie-<'.  nnl'iirtnnately,  the 
di-tiiiclion  tictwceii  ty|)lm<  and  typhi. id  fever  i-  imt  alw.iv<  -tiHieieiitlv 
clear.  The  nin-ele-  ul'  the  cyel.ill  arc  nirely  invulved.  In  2  ca.-e-  I 
saw  >Iral)isniii-  develop  in  the  coiir-c  of  the  lel.rili'  -tap.  and  disappear 
.ii'tcr  ivcuvery  wa-  e-tahli-licd.  Other  anthoiv  have  iiieiitioned  >pa<ni-i 
of  the  individual  mn-ele>  of  tlic  eye  and  of  the  levator  palpelinim, 
fuilowed    l)V    |)tii-i-. 

Disturbances  of  the  Hearing. — In  contradi-tinetion  to  what  is 
oliserved  in  ty|)lioid  fever,  interference  with  the  sense  of  licariiii:  dno 
to  the  toxic  clfcet  on  the  auditory  center  in  the  lirain  or  on  the 
auditory  nerve  appears  to  lie  rare  in  typhus  fever.  Mv  own  exiHrience 
compels  nie  to  cimtradict  Ficlicit's  statement  that  the  hearinfr  lieeomcs 
atfectwl  toward  the  end  of  the  first  or  at  the  hesrinniiiL'  of  the  se<'oiid 
week. 

As  a  rule,  auditory  distiirhances  do  not  make  their  appearance  until 
the  jxjriod  of  convalescence,  when   they  become  comjuir.itively  fretpient. 


■--!r' 


",!■: 


•)»-  I )  rill  N  /  /  I  /  /,' 

riif\  irr  ii~ii;ill\  (liic  I..  -«>  lliiiLT  "i'  iIk'  iiiiirMii-  iik'iiiIm'mik'  lining'  llic 
|-.ii-t;iilM:iii  mil.-.  .iu<l  I.I  .aliii'ili  ..t'  th.    t\  iiipaiiiiiii,  .  n.liii;;  -..lii.hni.-  in 

|iiinil.iil    .itili-    iiii'.lia    uilh    |>.fi;ir;ili f  lli.-    i\  iii|.aiiii'    ininilii'aii.    ..r 

(■\.ri  ill  iiitlaiiiiiial.in  .|i-<a-«'  ..(■  llic  lal.\  liiilli.  <  >.■.  :i-i..iiall\  ,  tin  .■..ii- 
.lili.iii  f:i.<-  .III  .MM  I.I  |iiinili  III  iiitillrati.iii  .il  tlif  ina^tuiil  crll-  v\it|i 
|iii  iii-liti.'   all-..--.-,  iiiM-,--i;atiiiir    -iill;ii-al    int.iliriii..'. 

I'li.M'  iii.irl>i<i  iliaii-.  -  all  (|.|Hii.|  oil  till'  liy|KT(iiiia  and  -wrlliiiLT  i^f 
ill.'  iniKMiu-  iiii'Miliraiii' lit'  tlic  im-.  anil  iia-.ii|.liarvn\  tlial  aiv  |)(H'iiliar  t.i 
tv|iliii-  llv.r,  an. I  .livcl.i|.  iliiriiiir  ih,.  Hi^t  i|a\-  ..f  ilir  ili~ia-r. 

\..-..niiii|.r  n,  my  i\|iiiii!iri.  in  M.ialiil,  tl„\  ii-iially  inil  fav.mihlv. 
Mi-l  |ialii'iil-  uiiv  iniiniy  (Vit  rr.mi  aii.lil.ifv  .ji-tnrl.an.i-  whin  tiii'V 
Wit.'   .ii-.-liai'tr.''l. 

I  liinr  iiiiiark>  nil  .iisra.-ts  lit'  til-  car  art-  liaM.I  |)riii.i|iMllv  mi  tlic  'mwvu- 
tiLMIi.iii>  iiia.li-  In  llartiMUiiii  '  .m  ,iiy  |iiiliiMl.s  in  Muaiiit  in  IST'.t.  'I'lusi' 
iii\i>li^Mli.iii>  a|i|K'!ir  I.I  lie  ihf  ni.iiil  ii.'.iirali- ami  iim-l  .■.iiii|ilitc  that  liavi' 
api'iari.!  on  liii'<  Milijii'i  up  t.i  tlir  pi.M'iit  liiiif. 

AiiimiL'  !•'!•'  III. 11  «li.iiii  III-  fxaiiiiin'.i  .Iniint:  tin-  |.rri."l  nT  .■.nuali'.viMi.'f, 
Hariinaiiii    t'.iiiinl    aural    .IImiim^    in    ij.  nr   :'.'J.:l  prr    i-riii.       Ili>   lalili-    i-^   a« 

t'.ill.lWM 

An  Ullilll.'ili"li    III'  rrTlllil'-n    in    ill.'  .■  \  l.rill.l    1111. lift!     Ill.illU-  (i 

Sw.lliiiL'  ■  I'  III'   ml..-  \Mil]  .  i.i.iiili  ..f  ih.    t\  iiij.uiiir  iin  in  14 

A.  I  It.-  inll:iTniii:iii..ii  ..f  th.    n  nipani.-  .  .-i\  iiy  withiiiu  p.  rt'i.niti- -n  •■!■  ili.-  ni.-inl.niii.-  I 
A.  ut.    iTi;l:iniiijiiti.iii  witli  |..-rr.  .riili.m  ..I'  I  In.  I  wii|Mni.    111.  111 1. ran'    ;  '.  .  11-1-  «,  r.-  uni 
l:il.  r:il,  I!   I'iiat.-nil  ;    H  '■:i-.-   u.-i-.-  i-Mni).lirat.'.i  wiih    prn"-iili-   "I'  ili.-    inii-l"i.l 

pr ■--.   1   '-a--  u  il!i  .-Mit'.-rant  '.rraniil.  -  in  ih.    .  xl.-rnal  aiMJil'Tv    ni.-Mlil-  i  !. 

AL,"_'r:i\  ali"li  ..f  linnilu-  ailliilin  an. I  .liltj.  iilt   h.-arin-  |ii nt    I'.-I'.n-  tli.-  .li  .-hm'  '■', 

l!.''-iirn-n t'un  '-i'l  "t"rili.  a                                       .             .  ] 

'rihnilil-  aiir-iiin.    v\  M  ti"UI  "l.j.-.-ti  \ '■   tin.iini^s ...  1.' 

IlK.'a-"-  ..I' till'  lal'\riMli      .                                 •> 


Niiiliiiii.'  .I.'iiiiiii-    i-    kii.iwn  iif  aiiv    ili'i'|iir  alterations  'in  the 

nose    than    lli.'   Iy|ii.-ai    .-alarilial    atlii-ii.ni   aln-ailv    iiii'nti.iin-ii. 

Till-  ...-.•iiiT.-n.'.'  ..t'  .-|ii-Ia\i~  .JiirinL:  th.-  tii--I  -taii.-  ..f  llii-  iji-i-a-c,  :inil 
i'\i-ii  li.-liir.-  ih.'  Iii-.j-iiiiiiiii..-  Ill'  llir  t'r\rr.  i-  \v..rtli  n.iliiii;. 


CHANGES    IN    THE    RESPIRATORY  ORGANS. 

'I'll.-  \ari.iii-  pai-N  ..f  ihi-  ri'-|)iral.irv  Ira. I  all  ]i,irli.ijial(-  in  tin- 
in.irl.i.l    pr.i.-i'"   ..I'  I\-[ihii-    r.-\i'r. 

Til.-  i-atari-li  thai  all'.-.Is  tlir  nn-i'  ami  na-.ipliaryii.\  -jir.-a.l--  iininli-i-- 
riipt.-illy  III  til.-  JaryiiN.  tra.-li.-a.  ami  In  th.-  .-i.:ir~i-r,  a-  wrll  .•i>  tin-  liiii-r, 
raniili.-aiinii-  nt'  tin-  lir.m.lii. 

Tlii-  .-atairli  ..f  I  he  n-pirat.iry  livi.-l,  .--p.-.-ialh  ill.-  Iirnnrliiti-.  is  to 
111-  n-^rariliil  n.it  a>  a  i-Dinplii'ati.in.  hut  a.»  a  pci'iiiiar  ni;iiiit'c'st;itioii  ut' 
'  Zcitsc/ir.  f.  <)hrtnk.^   lid.  viii  .   II.  :!, 


SYMITuMA  Tdl.na  Y 


>  \-\ 


Jy|>liiis  fiviT.  It  <:iii  piuTilly  lif  ilix  niii.l  .liiririL'  the  vcrv  lir-t  «la\  - 
ol  tlir  (li-ra-c,  ic.iclir^  it-  (.'f.Mtf-t  iiitni-ily  mikI  uiilc-t  di-t  liliiitiiMi 
tlin.ii^lii.llt  tllc  lito||i|ii:il  live  (lliliii;:  til,.  Iici;:hl  (it'  llic  IMui'liiil  pnic  — , 
ami  lir^rji,.  In  .,|||„ji|,.   with   ill,,  culf.llicliccliii  lit   n\'  (li  lrr\  i-cfll.r. 

Tracheobronchitis.— I'll.' iiilliiiiiriiaiidriul  the  ini.'liraaii.l  bn.n.lij 
i>  arciiiipariicd  t'niiii  tlir  vcrv  lM;:iiiiiiii^r  li\  l'rii|iiiiit  nm^li,  w  iih  lnu 
>lii;lit  (AiM'ctofatiuii.  In  Ian.  |||,>  ,;,\,.^\,  \.  airniiipaiii.il  liv  \i<\  >li-lii 
fX|M<tiiratinii  liiiiini;  tli..  iiitii-c  di-.a-r.  Tliis  iiiilativr  coiij;!!  i«  |«i;- 
tiiularly  ili-tfi  —  iiijr  diiiinj^r  |||,.  ,.;y,\y  ^i-,;;,.-,  ,,ii  ac'cuiml  (if  tin-  a.iitc 
a;:i:ra\atiun    i>\'  tlif    liiadaclii'    tlial    it    cMca>i(iii-. 

1   liavc  seen  siiirlii  tm,,-  nf  lil I    in  t),,.  M-anty,  -lairy  <\|.<i|,,i-;itinii 

loliowiiiir  >evcrc   |.ati.xy-Mi-.   <<{'  ,niijr|iin;r,  ;,||| ^r|,    ,|,,|   a    ti^UT   III'  anv 

tiilMTcill(»is  \va-   |>ic>cnt  ivcn    then  ur  lat.i.       Tin.    iucmii.c  <.t'  a    tni.v 

(il  l>l<Mid  is  readily  a<- nit.d  llir  wlun  .me  rcin.inl»  r-  tlic  iMraordinarv 

swelling,  niacoratinn,  and  intm-c  rcddmiiiir  "f  tlic  n-|.irat(ir\  inncins 
iiK'inlinnii'  so  nCtcn   iil)srr\cd  at   the  antu|)«\. 

Tlic  alcl.rtatic  cunditiiin lnl.nlar    |iiitiiiiiunia   aiiil    liy|.o.tatir  <un- 

P'-tions  .if  the  lower   lultc — arc  niid"iil)'c<lly  d.i).ndiiit   on   tl atarrli 

of  the  liner  hronehioh-  and  the  eardiae  u.akness  that  is  iir.-eiit  in  all 
severe  cases.  nyiio-tatic  con^-tioii  ii-ilally  iicirins  to  develo|)  hetween 
the  tenth  and  tlinrtccnth  day-  of  the  di-ea-e,  at  the  time  of  jrreate-t 
l>rostration— rarely  earlier  or  later~aii<l,  a-  in  all  acute  infections  dis- 
eases,   it    is    of   e.\cc(Klin;:ly    iniliivoralile    proyno-tic    siirnificancc.      A< 

1    liave    mentioii.-d    in    a    li.r r   -cetion.    it    is    never    ahseiit     in    the 

cadavers  of  typlin-  lever   patient-. 

The  older  authors   lay  trrcat  -tre^^  on   tlu enrrence  of  diphthcri.- 

aH;'eiion-  of  the  rcspjnit-.ry  tract  l.oth  in  the  no-e  and  na-opharvnx  and 
<lown  to  the  tii„...t   rainilication   of  the   lironclii.      They  o.vnr  e^iH-eially 

ni    sc\ele    and    c\Ien-ivc    epidemics. 

Wc  uliscrvod  this  coiidilini,  il,  .-,  ,..,.s,.s  in  ISTMaii.i  IM7!).  and  in  all 
the  nsiill  was  tatal.  In  ;i  of  the  ca.-es  tra.lieuton.v  was  |K'rfortnp.l  l.iit  tlio 
paticnis  succMmlicd.  as  the  pn...es.s  had  exten.le.l  into  the  ni.isl  n,iiinte 
rann hcatiuMs  ol  the  hronchi.  Whether  ihes,.  ,|,.|H.sit.-,  are  mere  dii.htheric 
n.e.Mliranes  ,n  the  ai.aton.ie  sense,  or  whether  thev  are  to  Ik-  referred  to  the 
Klel«-l/,tticr  l)a<illiis.  is  a  ipiestion  for  fiilun    iiivestiirators  to  decide. 

.\inonjr  other  -evciv  .and  iin|H,rtant  di^'ases  of  the  re-pii-,torv  tnict 
those  allw'tin-  the  larynx  deserve  partienlar  mention,  as  they  atr.'.rd  the 
best  explanation  for  the  varyin-  fre,|ueney  of  certain  niorl.id  phenonienii 
in  ditferent  epidemics  and  the  diir<Tent  perio<ls. 

.Miirchison,  with  his  wi<le  experience  and  the  extensive  liteniturp  at 
Ins   dis|K)sil,  does   not   apiK-ar   Ut    have   liiv..<t;.r..»,»I   tl,;..   ...i.; „_.. 


Ml 


/ )  nil  s  1 1  \  1 1: 


■  •«  T  ■    "7  ^  -^nli 

II 

|g 

iIi"|'MIl:M\  .      Ilr..iil\  iiiiiiiiMii-  ill  |.;i--iML:  llir  iii-ciirrciicc  lit' trv-i|Hl;il<iii< 

i|i-ra-l-  "I     till     l:l|-\ll\.  \r.  iililiri;.'   In   lri\    iiWM   l  A  JM-fii  rii  i  .    lllr    rli:i  rarliT 

"I  llii-  ili'li\  iilil.il  i|ih|.iiiii  \<\:i\  -  ;iii  iiii|Hii'l:iiil  |i:irt  in  llii-  iiimiil. 
\\  llilr  III  l^7>  Ui  li.nl  -r:iivr|\  :iin  -,miv  l,ii\n;^i:il  ilil^  rl  iMh-.  1 1„  ir 
ihiiiiIh  r   «,i-   .ili-nliih  U    It  rrilv  ill:;    ni    I  s7!i. 

Changes  in  the  Larynx.      rii.>   Linn-'il   r\aiiiiii;iii..ii   i-.   ti.r 

iili\iiii|-    l.':i-Mii-.   \rr\    liillii  lilt   iiinl  imi t   ii|'|,ii    I.,    i;iniiil    mil.       \\  Inn 

il  i-  |i.."iMr.  Ih.ui  \(  r,  ill.'  ran-,  ..|  ili,'  Imar.,  n,  ~-  ,.l.-,  i\,i|  iliiiin-  ilir 
lii-l  u..k  i-  I'l.iitiil  1,1  l„  a  -iiii|.l.  lalairlial  r.  .mill  i..n.  niliir-  ami 
liiai  1  laliMii  111'  llir  M  nliinilar  l.iii.l-,  uilli  ili-,i,|.  nvn  i,.ii  ul  tlic  \  a  ,ra  I 
'"i''l-  ^iii'l  miiiImiI  -\m  Hill-  ,.r  ill,  mil, -,,11,  imiiilii'aii,'  ,,.\rrlii::  ilir 
ai-M,  miiil   carlila.', -.       S|i._'|ii    ,i,,-i..n-    air    al- ■,-a-i,iiiallv    |„  iv,  |,i  il  ,1,  . 

I  lli-r  iliallL.'!-  Il-liall\  ili-a|i|i,al  ,  ■  .III  |  ,|,  I  il  \  ,  a  m  I  llii-  \iii,,-  ijlilin.j- 
f.iiuali -ciii-,..  wliilc  wiaL,  i-  |i.il,,|l\  liar  i.r  al  in. .-I  \,a\  -li^rlilK 
lii.ar-i  . 

Ill  ■•!   i-iTIaill    miliili,  1'    I.r   r  i-i  -,   nil     llir    i.llii  1-    liami,   lli,      iiiilial    -\:fjr<. 

ari-  |,.li,i\\,  ,|  l,\   111.. IV  |>i,.|: I  ail,  lali.ih-   in   il  .    Iar\  ii\.  \\  lii,li.  ,il  hi  |-  in 

lliiiii-,l\ ,-  ,,r  ri'iiii  llir  ,',.ii-ri|iii  111.-  lliii  l..l|.,u  ill  ill,'  ri'iiiaiiiiiiL'-  liiii- 
li"ii-    '.I'   llii'    iv-|.iial..r\     trail.  nia\     In    nf   tin-   -i'a\i'-l    -i.jiiiti,-alir,'. 

III,-,.  III..I','  -,'\iiv  I'liaii;:!-  liiri.iiii'  nianiri-l  ijiiiiiiL'  tin'  liii^^lil  i.r 
tiiwanl  till-  I  ml  nf  llir  I'l'lnil.'  |M'ri.„l.  ami  a|i|irai'  In  lakr  llnir  nri.^in  in 
crii-inii-    Miiil    ti--iiri'>    nf   till     |.i.-iri'ii.r    lai-\  iil..i.iI    wall. 

'I'llr-r   ilrl'ri'l-    a  fi '   illlr    ,|il',,'li\     |,i    ||ir   ,|l'\  ia-j-nlU    ,.t'  ||i,'   allraiU     lliari  - 

rail    I  am!  |iarliillv   ili-iiitiLri'a|r,|   nimi.ii-  in,  ihIumii,  .  r.ni-,,!  |i\    {]„ ,,. 

-taut    im.iilli-liri'.'itliiii;.'    nf  tin-    |ial;,'iil-,   win,  .ii    ilii-    -i.i;;,'  li,'  jn  a  -niii- 

lnll-,i.,ll-      ,',lll,|iti,in      \\illl      lllnlltll      will,'     n|lill. 

'I   lll'-r    ti--lirr-    nrriir    |  H  i  llii  |  la  I  I  \    nil    llir    |.n-ll'lii.r  U.'lll.   \\llil'll    l'lri'«   llil- 

lull  I'inr  nt'  llir    lar\n\.  ami    i|i'\i|n|i    im,,   i'\i,'ii-i\ ,'    nlci'-    tliat    ~|ii"ai| 

II-IImIIv  In  nil,'  -i,l,'.   ami.   a-   tllr    llln  l-.lt  i\  i     |iini'i  --    l„  ,',  .111,.-   ,1,',  iirr.  a  I  lark 

llir    rarlila'.'-r--    I.r   llir    |ar\ii\.  |i.'iniriilarlv  ikr   .-irv  h  in  i,|.      'I'li,.    miirnn- 

iiii'iiiliranr    rn\  ,'rini.r  (In     laUrr    -will-    ami    li.nii-    a    -ii ill.  I.|iii-li-r,'il. 

riiiimli-li  tiiim.r  ,i.\  ,'iv,l  liy  a  wliili-li  rMiilaIr,  wliirli  in  ilir  Inrin  nl'  an 
nirlllll  -prrail-  In  tlir  nrii.r|iliiirii|r  |,nrtl,.n.  ami  tllr  clltirr  (litnilifr  II  tj.c 
laryii\,  ami  may  srrinii-ly  rm'  iiirrr  lii,.  ii.iiiinr-  lil'r  li\  a.-|ili\  xia.  'I'lio 
jiatirnt  liriii;:  ii-iiallv  in  a  \i"y  Inw  mmlil  imi.  (|iiilr  iiiiriin>i'ii.ii-.  iiir.i|i;i- 
lilr  nf -(.|f-rniltrn|.  ami  -n  -.vrak  tii.il  llir  Iriiiaillini.'  tlirkiT  nf  lit'rraniint 
n-i-I  ('V|.|i  tllr  -li._r|itr-t  (IrLrrrr  <-t'  i|\-|iiira,  tlii-  ilai  T  i-  \i'r\  ^.Tcat, 
ami  it  is  nt'  LTn.it  iin[inrt:iiirr  tn  liiar  it  ii>ii>l;inllv  in  iihikI.  liciirc.  in 
any  M'vrrr  ra-c  tlir  larlii-t  a|)|)('arani'r  nf  ryann-i-  nr  ;mv  ntlirr  svinjitniiis 
nf  intcrfrrcnri' with  ri-[iiralinn  mii-t  In- cMrcfiilly  ioukiMl  tor,  and  traclic- 
ntmny  lir  |ii.rli)riia.il  withniil  iiniliic  dclav. 


M  MriiiMAI<'l.iii,  Y 


i 


645 


Tn  tint  :i  few  .■ii^c-  |MTiiliciiiilrit'-    IcmiI-   u>   m 


.f  tl 


ir    (•.irtll.iirc, 


II. ..I 


i-M>ii,iilv  cwii  III  i  nrn|>li  ic    -.iLiraliiiii    ..f  llic   cartiLi;.'!'    I't-i.tii    it- 


jiiii  iil- 

ln\'-l'll'     nllc 


llial     II     lie-     I 


I'll'    ill    till 


ill 


■l|ii|-:ill 


taki-    |>l 


|iu--ia\  it\ ,  am 


till'   I'a 


til; 


I    if,  a-    I 

IL'i'     liia\     111' 


'\|.' 


Ill    \\liin    till'    |iali(Nt    iiiii;.'li-. 


It  ilialh  i-  aviiiilnl  in  hkIi  la-i'-  l.v  tiniily  iiiti  rt'iri'Mci',  tlir  |ii  limt 
i.r  ill',  rvi'-iiiH'c  i-  ii-iiall\  I'Stiaiii'iliiiarily  pn .|oii;:..,|.  .\-  a  riili-.  tlir 
l-atii'iit-   .'111'  viii.il,.-.-.   I'm-  III.'  iiiiiaiiiilir  of  ijnir    liv,-;   ami   s,,im  tiim-- 

"' ~'~  "I   ''i'    l:ii-.vii\  iviiiaiii-.   uliiili  n  i|iiii',',  a  Imi;,' ami  tiilidii,  .uiirM' 

iif  tiiatniiiil  111-  fii'i'i-.  ill,'  |,atii'iil  tn  u .  ir  a  .aiiiiiila  |M'niiaiii'iitl\ . 

'"  "'  'I''"  i-'  I  ['.■■■'viii.^^,|-,,iiri.'i-.'>ir.ni('.|  in  tl,,  MnaMl  laA-intlu  in 
!.><,'.»  til. 'n'.Mi'iirri'il^i'vi'ri'  iarvii.'cal  airii'tii.ns.  'flii,  ,l,,i's  imt  iiii'linl,.  a  Mill 
irr.atcr  iniinl,,.r  ,,f  |,alicii|.<  win.  i|i'v,'|i,|«..|  ii,.nrM'm'.-vs  ami   ••..in|.icl,.  a|.l'..iiia 

lit  til.'   Ii.'itrlit  i.f  III.'  ilisi'MM'.  I. lit    in  wli tl..'  v..ii'c  was  r.'st..rc.l  after  tli.'v 

r.'.'..v.'r.'il.  In  t  .asi's  lrai'l..'..t..iiiv  L.-iainr  ii..'.'.«.sarv  i.ii  R.c.unt  ..f  iHri- 
rlmiiilntis  I.f  ..n.'  of  tlii'  aryt.'m.i.l  lartihiL'i'.-*  ami  ri'siiltinu  cil.'inn  of  tin- 
larynx.  1  lir.T  ..f  tli.'s..  r.'.'..v..r.'i|,  l.iit  lia.l  to  w.-ar  tin-  caniiiila  «.  |,,n;:  .u» 
lli.'v  w.Ti'  iniil.'r  my  nl..-,-rvali..n  ;  in  tli.'  fourth  .•list-,  oiifrutive  interference 
Caiiii'  Ion  late. 

reii.'li..ii.iriti.-  al.M'e>-es  are  iim|i.iil.t...lly  the  illrei't  caii-H'  i.f  many 
.^POTC  i.iilim.iiary  ami  |.l.'iiriti.'  ei.ini.ii.'atioii-,  piirtiiiiLirly  certain  foriiH 
«>f    lulmlar   ami    ii.l.ar    |iiieiiini>iiia    cmliii;:    in    t'liiitrreiie    i.V   piiijrrenuii.s 

|)leiiri-y.      They  arc   [.rmiiic,.,]    I.y  aspirati f  -eptic   mn'-sfs   from   the 

al.scov's,  u'lich,  a.^  Nvc  have  .-cii,  teiiil  I.,  niptiirf  into  the  interior  of 
the  laryii.x  after  a  certain  time. 

I  Ml.  not  iiHvm  to  siy  that  all  <"i..e>  of  p,„f,r,.ne  of  the  limgs  ami 
«'iiipyema  are  refenil.ie  to  purulent  amvtii.n<  ..f  tli,  larynx,  for  then-  is 
III)  (loiiht  that  piitriil  inriammations  of  the  piilmi.iiarv  ti.<siics  may  I.e 
proiiiiciil  in  ways  other  than  I.y  aspir-ation.  I  ,|i.  maintain,  however, 
lh;,t  inf.rtion  from  the  larynx  play.s  a  very  much  more  important  part 
than  lias  hitherto  l.eeii  siippo^cil  or  reiH.rti'il  in  the  litcnitiir.'. 

During:  the  e|.i.leiiiic  of  1«7!'  we  i,l,«.rve,l  ti  ca.^e.s  of  fraii-reiiou,  i|i....aie 
ot  the  liin^rH  ac.'onipaiiyniL'  |KTii'h<.mlritic  al,«'es.s.  Five  of  the«.  .K-eurreil 
in  tlieritrht  lower  |,.l.c.  which.  ..win-  to  its  shaiH-  am!  the  conrse  of  its  prin- 
cipal hroiicluis.  apjK'ars  to  he  much  „i,.re  a.'ces«il,le  to  aspirateil  .natl'rial 
ttian  Its  fellow  ot   the  left  siilc. 

Five  of  these  ca.ses  enileil   fatally-th-  total  numher  of  .leath.s  was  !»:? ; 
le  .sixth,  n,    which    there  was   a   small   circuniscrilK..!   frant-'renous  focus   in 
the  lower  lol.e  ot  the  riL'ht  liin-    finally  cmle.l  in  recovery  after  a  prolonged 
illiies.s.  ami  after  the  laryngeal  aU'ectioii  ha.l  l>een  cured.  " 

Diseases  of  the  I,ung  Parenchyma  and  the  Pleura.— 

AmotifT    the    most    frequent    pt.lniotmry    diseases    in    tvplms    fever     in 
addition  to  the  atelectasi.s  and  hyi,.,8tatic   conire.stion  that    have  .-dn'mlv. 


^1 


iCJ 


■,>,  ,-1  .f/ 


[)Ui 


TYri/rs  I i:\i:i:. 


I..VM  ril'.nvd  to,  is  :i  i;,n„  ofliln-iiious  |>n(imi...iiu  tliat  rnnnot  hv  di.-tin- 
KNi-lici;  iiiicn.M,,|.i..;ilIy  \\;nu  tlir  oniiiwuy  (uniis.  N,.  l>M<'tiriulni:i,< 
(■XMiiiinaliMn    |ia-   s.i    t'ar    Ixcri    niadi  . 

It  <Kv,l.,|,.  in  the  ^cMiid  u.vk  ..f  til,.  ,li>cas..,  raivlv  ,.aili,i-,  and,  a- 
tlic  iMticiii-.  ..t   tlii-   lime  arc  u-iially  in  a  Mu|.on,iis  ,ir  .•oinatosc  coiidi- 

" ''"'I'''   ='!■'■    1'"    'narkril    -mm|,i, .nir-.      ( )r,"i>i..Mall_v ,    an     iiirrcar-c    in 

tlir  n-|,iralun  yaw  „v  a  rin'  of  tnnjK.ralniv  |M,inl>  to  its  o.vnrmirc. 
KuMv  s|mtinn  ..r.  In  fart,  cxp,,!,, ration  ,,f  any  kind,  is  ,,ffn  al)s.nt. 
Only    tiv,,ncnt   an.l   ravfnl    cNaniiuations  ,,f  the   patient    will    tJRMvforo 

insure  the  d.t.rtion  ..f  this  r pli,  lii,,,,.      J    ,.,ni    inclined   to  doul.t  that 

the  marl. led  and  aliuo-t  whitidi  appearance  .,f  tli.^  inliltrat.d  iK.rtioiis  of 

tlie  hnifT,  pciiued  ont   l.y  Saloni ire  dne  to  any   pe.nliar  patholo^dc 

alteration.  Th.y  are  more  uatni-ally  ex|>lained  hy  tiie  general  anemia 
tliat  is  usually   pre-iiit. 

Fil.riiious  piieuiiionia  in  typliiis  ti'v.T  varies,  as  re-ards  tlic  frcMuencv 
of  Its  ...riirrcnre.  ac.-ordini:  In  lime  and  place.  <  In  the  wlu.le,  il  appears  to 
l;e  dislmetly  more  t'rccpient  than  in  Ivplioid  t'ever,  and  rnn.s  a  (leci.le.ilv 
more  severe  course.  lu  I.s7;i  uc  had  to  report  lihriuous  pucmuonia  as  lli'e 
immediate  .■ausent  .leatii  m  1  1  cms,  s.  or  l,".  per.vnt.  of  all  fatal  ea.ses  ;  hut  :{ 
cases  in  whii'h  this  iliaL'Uosis  was  niaile  ended  in  n verv. 

Inllamniation  of  the  pleura  i-  al-o  diMim^tly  more  fre<|uent  than  in 
typhoid  fever.  It  is  apt  ...  |ol|,,w  loluilar  and  iol.ar  pneunionii.  and 
especially  pnruleni  pneumonia  and  lea.i-  to  purulent  and  putrid  etfii- 
sioiis,  >,,  iliat  operation-  for  emp\,i,ia  .-iri'  indie  often  reipiired. 

The  pleuritic  aU'ec'tioiis,  like  pneumonia,  are  (piite  likely  to  he  ,,ver- 
look.d.  Tlu-  pati.rfs  ,,ften  do  not  ••omplain  of  pain  in  the  nde,  and 
plcuriti.'  friction   1~   fivpicnilv  al.-cnt,  partiv,  no  doid.t,  on   acc,,iuii  of 

''"'   l»'<'iili:ii-   -"ft    ' dslcn,,.   ,,f  ih,.    lil.rinoii>   exudate,  aixl   j.artly  also 

on   aec(.iint    of   the   linulid    re-piratory    movements. 

•^' ''   •'"   ^I'lihor^  atrree   in    mentioninjr   piduK.n.ary  tid)crculosis  or 

jrt'iicral   miliiirv    tuli-rculod-    a-   ; ccasional    pliiMtii.n   of   tvphus 

fever.      It  ma\    make  it-  appearance  during  the  height  ,,f  the  disease,  ,,r 
even  diu-iii;:  the  lat.r  -lau'fs  of  c.,iival<scencc. 

I''r(,m  our  pre  cut  knowkd-eof  •'.•  .Iisca-c,  it  i-  <•(  riain  t!rat  -ueli 
ca-c.  arc  :d\\av-  .lue  to  .-I  lao^ni  tui.enadod-  that  has  he.n  lij:hte.l  u|i 
»,L'ain  l.y  the  typlm-  fc\cr. 

.\iiinMir  the  pati.M.ls  under  mv  care  in  I.S7.S  ;i,|,|  i.H7<t  there  was  1  case 
of  L'cneral  miliary  tid.crculn.is.  »  .-a.-,  s  of  fulminatirii:  i  (!,,rid  i  pulmonary 
plitinsis.  mikI  1  case  of  chroiii.'  ulcerative  iiililtration  of  the  lower  lohe  of 
the  left  huiL'.  followin-  immediately  ..u  an  acute  luhar  lihriuous  n.nsoli- 
d.'itioM. 


Ml 


sYMI'TOM.injl.OGY. 


547 


ALTERATIONS    IN    THE    DIGESTIVE    TRACT. 

Di-.Mivc  .liMMihan.v-  niv  of  Cr  1,.,.  impurtancc  in  typhus  tlun  in 
typlioiil  Ccxci'. 

'I'll.'  mI.mh.v  ,,(•  .|H.,ill,..  n-ul,nly  ir^'unin^^  :ilt.rali..tis  ,,f  il„.  i„i,.,. 
tiinl  -■Mn.il  in  lypliu-  i;.v.r  l,:i~  aliva.ly  lurn  ].uint,..|  .,nt  in  ,!„■  s.Ttion 
"M  l'ath„l,,^.y.  A,v„nlin,irly.  il,..,v  is  m1>,.  an  al.son.r  ..f  pain  in  th.. 
n-inn  of  tiir  Mnall  int.-.in..,  and  any  n.^tcwortliy  (lofrroo  .,f  tympanites 
IS  rarely  <,l,~,rve,l.  I  i„.|iev,-  lliat  it  ...■eiimd  in  only  1  per  rent,  ofniv 
cM-es. 

I'ain,  |.Mali/e<l  in  tl,..  riglit  iliae  n.,ri„n,  with  fimvlinp,  never  oeeurs 
in  typhus  fever. 

As  tliere  is  n.)  (•..iistancy  in  the  anatomic  app«iranees  of  th.>  int.s- 
tinal  eanai,  thi're  is  a  eorresp,,n.linjr  al.s,..,<-e  of  rejrularity  or  anvtiiinjr 
espeeia'-y  eharaeteristie  in  the  fre<pieney  of  the  stools. 

As  ..  rnio,  there  is  constipation  .hirin^r  the  first  week,  and  not  rarely 
•Inrinj:  th..  entire  period  ,.f  the  disease.  I^Uer  on,  espeeiallv  at  tiic 
iKijrht  of  the  disease  an,|  d.irin;r  ,|,.f,.rvescenee,  .liarrliea  occasionally 
"•■'•iirs.  I  hclivve  that  aleolh.ji.s  are  more  disiH.si.l  to  .liarrheu  than 
other  patients. 

Then,  i,  n.-thin-  characteristic  alx.ut  the  appearaiuv  of  the  stools, 
even  when  tln.v  are  seiniii.piid  .,r  .piite  thin.  Th,.  stateniems  ,.f  c,.rtaiii 
phy~i..ians  that  the  sto„l>  r,.semi,l,.  th,.  ,.hara,tcri^tic  ,H.a-sonp  stools  „f 
typlioi.l  f,.v,.r,  r,.<i  .in.ply  on  s„,H.rli,iai  ol,s,.rvatio.,s.  \Vho„  th,.  ,Ii,.t 
.-on-i.-ts  prin,.ipd:y  uf  ,„ilk  an,l  l.roti,-,  ,1,,.  >t.K,ls  mav  he  vell..wisi,- 
whi...  m  lor,  iMit  th,.y  .-ire  n..v,.r  wat,.ry  an.l  fr,,.  from'nm,..is  tli,w  is 
>"•  «''id,.n..y  to  M.paraf.  in  !ay..rs,  an.l  the  .-oars,.  .ninnlar  s,Hlin...nt  and 
sharp  a.mnonia.-al  ..d..r  ..haraeteristie  ..f  typl.oi.l  fever  ar..  alto-.tluT 
wantinjr.  "" 

As  h...norrhajr..s  into  the  ^r-a^tric  an.l  inf-tinal  mucous  moml.nme 
have  ....cas.onally  I,,...,,  ol,...rv...l  at  th..  aut..psi..s  .,f  verv  sevro  ,-,.,sos 
tli..re  IS,  .,1  ..„„rs,.,  a  p„<~ilHli,y  „f  |,I,„„i  ap,H.ari>.jr  in  the  st.H.l  (P.an.I- 
l.er.  rw,...h..,  |.-r.,.i..hs  Mii.l  ,„h,.rs).  S,„-h  cas,.s  tnust,  howovor  he 
very  ,.x..,.pt,onal.an.l  th,.  r..port<  shonl.I  he  r..c..iv„l  with  j:r,.at  ..aution 
1I..1V  I.  always  a  pos.ii.ility  ,hat  th..  1.1,h„1  is  -implv  a  .-oi  .^omit.ant 
symptom  ol  a  h.inorrha^n,.  .|iath..sis,  „r  a  n.cre  lo.vd  homorrha-ro  fro„, 
th..  nvtum,  or  hom.u-rhoi.ls.  ,.„•.  The  stat..m..nts  of  some  of  the  oI.I.t 
aniliors  m  n.jranl  to  the  fr..,,„ent  ,H-.urreM,.e  of  int,.stinal  hemorrhape 
I'rohahiy  ,|,.p,.„d  ,„,  an  .rror  of  ,lia;:no-i<  l.etw,.,.n  tvphus  an.l  tvphoid 
(ever,  .m,...,  as  w..  know,  the  tw  .  -li-.-as..,  w..r..  n..t  infro,,uc.Ulv  con- 
<us...l,  as.   for  instanc..,   in    Kiijilaii.l  and    Inland. 


r-i^:^-^. 


OJS 


Tvnirs  i-i:vi:n. 


()Mo,.f  ll„.  ,•:,.,,-  „l,.,,.rvr,l  in  XiuiMt  ii>  l^Tltw.'ll  illiMnit,>s  llio  iumcs- 
sitv   (it   L'rc:il   cMr.'   in    JMdL'iir.'   I  lux-   lu'rimrrfiMLTs. 

A  vniiii-  Mian.  MV.Tiil  ,,fw|„,sr  iviaiivcs  Iki.I  ln-fii  n-catfd  in  tlic  hi/.a- 
rcll.i  tur  lypliiis  tVv.T.  an,l  \,  lio  was  u.lmill.'il  »itli  tvpical  ^vM,|,t,,^l>  cC  a 
M-vfi-e  attai'k  of  tlif  ilisrasc,  l.,i,l  a  innlusf  lifiiiin-rlia-.'  on  il;  .  niml,  ,|..,v 
nt  Ins  illness  that  fvid.'ntjy  canic  IVoim  sdini' cf  lie  In-li.r  |«>rtii'ns  ,,f  t),"^ 
mtrsiin,.,  At  Ihr  autopsy,  ihr  source  of  llu-  lu.n,onl,a-e  «as  louiui  in  a 
duodenal   ulcer  tliat   was  evidently  of  Ion-  staii.lin- 

'I'liere  i-  little  of  iinportaiiec  to  say  re<ranliiiir  other  j«.rtions  <if  tiio 
iiite~tinal  tract. 

Diirintr  the  llr-t   <lay  tli.'  tnnir,ip  is  thickly  covered  with  a    wiiiiish 

or   yeiln\vi~h-l)n,\VM   .'NU.Iate.      A-   tli<>  |.atient   l)e( les  iM.,re  and    ni,>r. 

ajutheti.'  and  hi-  mental  c..nilition  nion'  .loiKJed.  the  tonirno  l.ecomes 
leathery,  dry.  treniiiloiis,  c,,ven-.l  with  crusts  anil  niarknl  l,y  ilxurcs.  or 
smooth  an.l  iriazed  (( )l.erm(  ier).  The  ;:„„,.  and  li|)>  are  also  .Irv  and 
••overed  with  sor,|,s.  This  dryness  cannot  l.e  av.,ided  altofretlier  even 
with  the  lie-t  care  during  thi>  heitrlit  <d'  th"  di>ease. 

.More  nirely  there  i-  a  -.crhuti.'  -otteniuL'  of  the  ^rum<  and  other 
portions  of  tht   oral  mucous  memhraue.  with  a  tendency  to  heniorrhajres. 

The  soft  palate  and  the  ton>il>  are  at  first  of  a  deep-re<l  color  and 
inaeenited  ;  later  they  h.Kome  diily  yellow,  dry,  and  covered  with 
stnnil-  of  tenaciou-   u.ueus  and  drv  ernst^. 

In  a  i'vw  epidemics  and  in  rare  oases  diph  aeri.-  atfections  of  the 
pharynjreal  -tnictuns  occur,  Hdlowed  hy  Mip.rticial  or  even  deep  ulcers. 
I'ersonally,  I  have  >e<'n  ;!  ea.es  of  this  kind;  li  <,f  them  endifi  faUdly, 
and  the  third  reeoveri'd  after  a  nnieli  jirotracted  convalescjnoe. 


CHANGES    IN    THE   riENITO-URINARY   ORGANS. 

The  changes  in  tiic  kidneys  and  their  seereti..-,i,  so  far  as  i.s  known,' 
is  j)nietically  tli(>  >anie  a>  in  other  acute  inlW-tious  di-eases,  fs-.ecialiv  in 
.severe  eases  oi'  the  a<iite  exanthemata. 

From  the  very  earliest  tiays  of  the  disease  until  past  tiie  lieijrht  of 
the  febrile  period  the  urine  i-  scant  in  (piantity — that  for  twenty-fonr 
hours  nirely  exi'ccdin;:  from  KMHi  to  1-J(l(i  ,:>■  — is  hl^di  in  siKH-ilic 
trnivity,  and  stronirly  j,(id,  with  an  ahundant  sedimen'  of  u-ie  acid  and 
urates. 

.\s  the  fever  sul)-idc<,  and  diH'iiiL'  the  pecicHJ  of  conv.dcseenee,  the 
urine   is   liirhter   in   color,   clear,   aTiiJ   sometimes   verv   ahundant. 

(;ric"ini.'cr,  who  al-o  ,|U(ites  .Icnrier  and  Finj.cr  us  authorities, 
re|M'ate<lly  saw,  diu-iiiir  the  heifrht   of  the   fever,  a   teinjxtniry  .scvntion 

'  Tlir  in..-t  .npfnl  w..rk  ,.n  tlii-  .|i.,>ti.'ii  has  been  dnno  l._v  Prihruni  and  Itdii- 
silick.   \Vy<>.   ll.-.ii-t'iii.  iukI   I,:nic  ■r.'UU. 


^:,-?SMMi^VgII' 


sYMi'rnMATni.<)ay. 


549 


of  larp.  .luamiti.-  nf  ,.|,,,r,  pair  iiri,,,..  I  ,„y>.lf  hav  oLmtv,!  ihi, 
>rv..nl  till,,-  (-iMciallv  a  >lM.n  tiaic  hvi\,rr  the  l.c-inniiii:  „f  drfrm^- 
<vMrr.  T1h>  |.lMii.,ii„n,,ii,  wl.icli  1  Imvf  never  ol.MTVed  in  tv|,h,M,l 
liver,    is  ililMeiilt    ti,  explain. 

Durin-  ti...  hci-iit  ,,r  the  ,li-ea.-e  tlic  excretion  „t'  nre,,  I.  often  not 
iiMTea-e.i,  sonietinie>  it  i,  ,ven  diniinislie,!  ( Koseii.-tein,  Lan.cn. IX); 
wlnl<>   tlie  ex<T.tion    of  iiiie   aei.J   i.s   aiway-   di-tinetly    inerea-ed. 

I.:,  .eeraiix  even  »  lim  llie  patipiit.s  uere  takiiifr  lar-e  Miiaiititie.s  of  milk 
'"''',;■  "'"«"iy<l  > •'■  'liMi,  fi I  11.:,  to  l'4  -in.  of  urea  ii,  tNventv-four  hours 

Uoseii!.teii.    touiMl    mat    tlie   .eerelion    ,,f  „rea   «a.s   at    iir.-t  Voiisideral.lv 

lM'Tea.-<e.l  :  dliniii:   tli-  siil«e,,„eiit   rs.' of  the   fever  it   fell    far  l.elow  the 

phyMol-.^Mc  daily  ainouiit,  aii.l  duri.i-  .■onvahseeiiee  it  u-ain  r,«e  Kracluallv 
ills  lia.liiiL'S  show  a  reiiiarkal.le  a-reeiiieiit  with  those  ol.tained  hv  IJarallieT 
a.s  early  as  l.S(il. 

<  'theis  a.iioiitr  the  older  a,itiioi-s  I'arkes,  MiK^hanan  i  8|H.ak  of  a  eontitiu- 
ous  M.arke.  iii.ivase  iii  the  production  of  urea  .luriiiir  the  height  of  the 
..Hwi.-e.  1  he.se  di.^,repaii.'i..s  su-'est  the  neoe-ssitv  of  .'areful  invt^tifratioi.s, 
inriii-  tiinire  epidemics,  with   the   improved   me'tho,Ls  that  are  now  at  our 

(llS|lo>lIl(.,|. 

The  cl.ioiids  re^r„|:,rly  nn.ler-o  n.arke.!  .liniinntioii,  aial  .sotnetiines 
reach  a  inininiinn  di.rin-  the  fel.iiie  p,..-i,Hl.  From  the  iK-innin^r  ,{•  ,|„, 
sfVH.nd  w.ck  it  is  often  iii.|H.ssil)le  to  demonstrate  tlieni. 

As  we  shouM  expect  from  tlie  fre,p„.„ev  of  cioiniv  sw.ilin.r  j,,  d,,. 
kidney  .hiring-  tin-  liei>,dit  of  the  disease,  as  shown  l.v  m.moroi.s  autop- 
sies, there  is  nsuaily  a  tnodenite  fel.ril,.  alhi.n.innria  in   the  febrile  M-,.re 

."   severe  and  mo,leratcly  .severe  ,.,ses.      Tli,.  ail.ntninnria  , asionallv 

•imkes  Its  ap,K.a.-ance  ..,  early  as  the  iiii.ldje  of  tiie  first  wek,  tnore  fiv- 
qucntly  toward   the  ,.nd  of  the   tir-t  or   l„.;:i„„injr  of  ,he  .s„eoiid  week 
and  .iisapp«,rs   with   d..t;.rvescene,,  or   occ:,Mo„allv   a   (Vw  ,lavs    I.ef.n' 
that  perio,!.      M,eros,.opic  examination  uf  ,,„    ,„.i,„,  j,,  .„H,  ea-Vs  si.„ws 

"'  ";':';"""  '"  '•'">~'^' '■  -^>i'"<->-.  only  a  i;.w  epithelial  elements  tn.iii 

th.'  kKliiey  an.!  pelvis,  and  hyaline  .asts  in  moderate  mu, ;•... 

Neveivr  ...ad.s  of  albuminuria,  la^liiiir  into  the  [HTio.!  of  ,.onva- 
Icseetice  an.l  acconipaiii..!  l.y  |,|„,„Iy  ,„.i„„  „„,  ,„„„,„.„.  ,,,ial  ..pithelial 

'•-lis  and  ..pithelial  easts   ii,  addition  „.  hvalii a-t~.  indicate  paivnehv- 

"•atou-  nephnti-.  .a  cmiplication  of  imfavomMe  prouniustio  signiti-Miico 
"'^"    '"'•'"-'-..■!>   i.  rare.      in   a   ti  w.  I„i,    l,v  no  mens  all,  eases  i,  ends 

'="''">■  ""''  ^>"'l" -  "'•  i""nia.       i-lve  ,,i     .  i  .  w  hi,.||  we  cuiild  denio,,- 

strat,.  paivnchyiiiaton.  nephri,;,  at  the  ant-.psy  had  heen  dinicallv  oiiif. 
tree  Irom  nniiiic  -yniptoms. 

I'l   .v.umj:  in.lividnals.  e~peei,|K  i„  ,.|,il,|p,„,  ,!|„„„i„„Ha  with  al.iin- 

''"'•'   ^"'""^'''n-d'l.l 1   in  the  urine  has  l.,vn  olisorv..!   on   the   f.iirth 

..r   hlth  day  ol'  the  disea-e  ^Vei.s.),  even   hetore  the  ap,vara.u-e  of  the 


■i-'* 


ij.jo 


TVI'lirs  //•I/./;. 


•!.•« 


.(kX: 


'"'!" ■       '  '";  '"-"^""^'^  "■  -"■''  •— -  "  I'i-I'.  :.s  a  rnKs  .,v ,,li..„..,, 

'""'7"""""-  ' "■••'-   '-l-i.-i,„ila,-  lai.M,,  ,■„,„„„.  „.|„1,, 

"  •!"■  I'a...,,!.  Mu-viv,.  ,|„.  M.phriti-.  .Iirv.  a.a  ml,  uvAr  ■,  ..,„„' 
I'l"..'nr„v..ryan,.ravarial,l,.  p..,-,,,,!  „f  , :  .v..„v,.n  i,  ,.n,|„„l.,..,llv 
';"';•  ,  "':"■"■    ":"l'"":    "'^"'   ' I''"-i'-    ^' -,,a„vi„.-a.,,ina    -ia,,,!,., 

<ii|>litli(ria,  and    mmiIci  (rv,,-.  ' 

It  is  worth  Motin;:  ,ha,  .„„..  ,v,...,„  „l,..pv,.,.s,  \-i,.,„,,i,  an,,,,,.^  ,1,..,,, 
'"7  :''"^""-'='  l"-'iv,.   ,lia/„-,va,.,i„„  wi,h  a  iUW  .l,.^,-,,.  „r  n^MlaHtJ 
.n  t  M..r  ..,alw..  ,,r,v,.lH..  nrin..>,  .luHN..  a  p.in,  ,,r,inmari,v  U.,;....;, 
'•'"r  '';;'"'    •  ''"^■^'■-""1— •'"-■<■. 1,..  a..,,,.... ai„l„.,na,a. 

' '"•   "<-"nvn.v   of  M.,.ar    in    ,],.   urine.   ol....rv..|    in    ..v.ral   ,...   l.^ 

Lu-hanan,    l.a.s   „,„.   .„    ,:,r  ,.   j    ,^,„„^    ,.,^„ ,,,.^,^^^^,    ,_^  ■ 

autliiinty. 

Bladder  disturbances  -f  any  ..vrity  ar.  „.„  ,.r  fr.,.,n,.nt  „....nr- 
r.ru...:  an,!,  al. h.,n.|,  wc  n.,H.at,..iIy  f„nn.l  l,..n,.,rrl,a...s  i„,.,  ,1„.  nM„..,„. 
nxmlM-an,.  at  n,..  an,„,..y.  tl.  o..,.,liti„n  ha.l  „,„  ,...,.,„.,„,  ,„,.,.. 
tonis  (Inrinfr  lite.  •     ■      I 

l{.t..ntion  ofnrin,.  i>  v-ry  nnv  i„  ,n,.n.  Imt  ,,ni,..  ,,,„u„.,n  in  «„„„., 
-1..VIM  ly  .Innn.^   tl.   .la.ril,.   Ma,...      Wi,il,.  „,.   |,,.„,  ,„  „,     „,„  ,.,„„.„; 
'•"    '"al.s    u,    only  2  in.tan.v.    in    tl,:-  ..,.i.l..n,i,.  „r  IsTf.,  .   ,|ailv    or  at 
-•a^t   an   oo,.as,.,nal.    n.M.rt  t.,  the   eathet.r  wa.   n.ve.-arv   in   aln.o.t   all 
the    female  cases. 

I.,    rejranl    to   ehan,...    in   th,-   p.„it.l   ..rjn.ns   in    tv  ,,h„.    fever,   nnr 
Kni)ule<li.re   IS   very   limited. 

The   Male  Genital   Organs.-(  )rehitis  ap,.ars  to  he  oven  n.ore 
rare  ,n  typhus   than  in  typhoid   fever.      I  saw  a  Mn.de  ...se  of  uuil   ,enl 
..n  Hfs    n,a  youn«    n.an   shortly  heCre   the  erisis  ;   it    last..l    ten  days 
an.i   snhsided  v.thout    -roin.  on  to  suppurmon.      Most   of  the  authors 
do   not   e\,ii   mention   orchitis. 

The  Female  Genital  Organs.-On  the  other  ha.,.l  the  dis. 
«,se    ap,H.ar.   t.,   hav   a    mark..|    eff..,    .,n    the    fen.alo  jrcnit.d   ..n.n.s 
man.f  .tn,^  itM.|f  in  a  varietv  of  .ays.      The  e.i;.,.  on  menstruation 
1-  similar  to  that  olwervd  in  other  r.eule  infectious  .li.eaM- 

Th,.  onset  of  ,h,.  disease  „  ,|ui„,   nv,|,„,„lv  aecou.p.inied    l,v  pre-n-w 
ure   men.rual    ,Uv       The   ,1.,.  j.  ,„,„.    „,„„„  ,„,.,,.,  „,^,„  ,,  \ 
nml  oc.,Monally  the  hen.orrha^e  is  s,.  .„,„,,  ,.  ,„  ,,,^.,.  ^,  ,„^„.|^,,|  ^^^,^_,^_ 

:""r  "':•"■'  "'^"  -' -  !•-'"■-  ti.  sui,..,p.,„„  ..ourse  ..f  ti.  .h.... 

f    -h..d,<casc,„.,.urs   s|,.„^K,,^.,,,„„   last  n,e,.s,rual    period,  n,ens,r„a- 
.on  is  ahnos,  aluays  su-p..ud,.d  durin;,  the  entire  .h.n.tion  of  the  attack 
'"    '-I'l    <-es    th..    n.cMstrual    flow    ,vapp..rs   .,.,„   alter   the  ,,eriod   of 


VAUl.iTloys  !.\  rnl-nsi-:  AM,   .U.l.\7/7;,s/- ! /Vo.V.v  f,r  /-AVAM.s/;.    ,^-,1 

(lofcrv...«-..HT.   MM.I    luMv   ,.v,,,    |„.   inrnav,!    i,,    MMKMuit.      Alter   ^.y.  ,v 
<-MM.^,  on  th..  otiur  1,m.mI,  ii  .  :.,,,K,,r.inr,    mav  l„.  ,|,1avnl    fur  >..,„..   time 

Pregnant  women  do  ,„„  :,,,|H.ar  -„  |,;,v,.  .„y -juvial  ,„v.li>|K,- 

MtiuM  to,  i.ur  ,!.«-.  |.r.-iianc.v  uHonl  any  |.n.t.rti..M  a-ai.i>t,  the  diMa^o. 
I'll.,  rli;,!  uf  the  iiiala.ly  on  |.r.-i.ancy  lias  l.,vn  uv.Tf.-liinatf.l  l.y 
many  author-.  Ty|.l„i-,  lik,.  ,y,,|,oi,].  r.v.r  is  not  i.v  anv  niran-  >o 
-laii-i'ion.  to  a  |.r.Mrnant  uo.nau  as  i>  Nari,.la.  A  hxyr  ikt.v.iUijt,.,  if 
not  hair.  ..r  all  pn-iiant  wonini  havi'  the  .lisra-c  without  :  iitrn'i.ig 
ahortio  1  or  pn-niatiin-  l.ii.or.  This  i-  trnr  |.artirnlarly  i:i  cum  s  in  whirh 
tlu>  (lis,.;,M.  nialvos  its  appoaranc,.  .Inrinir  th,.  later  niontiis  ,,f  pregnancv, 
l.nt  even  -Inrin-  the  earlier  months  ahortion  i,  i.y  no  ,nean>  a  amsUnt 
oc.(.nrr(.n(.i'. 

The   Knirlish   physi.-ians,   wlio   have    pn.hal.Iy   enjov,.!   the  {greatest 
.■xpcricnee  ni  this  resp,vt.  l„.lieve  that  lyphu,  fev.r  ha-"  a  slijrhter  ettk.t 

""  ''" "■-'■  "*■  Pre-naney  ti,at.   has  any  other  a.iite   inlivtioiis  disei.se. 

Waniell  -tales  that  he  has  never  sein  an  interrnption  of  pregnancy 
-Inrinir  the  conr-e  of  typinis  ■'ever,  alll.on^rh  it  rn.ist  I.e  admitted  that 
Ins  -tatenu.nt  wonl.l  ,arry  gre.ter  wei;rht  if  it  were  ha.sed  ,m  a  laixaT 
niiml>cr  of  cases. 

Kveii  when  pregnancy  is  interriipt.KJ  l,y  tiie  di-.ase,  the  accident  is 
not  alwt.ys  fi.lK.w,,!  l,y  gniv..  con>(^,,„.nees.  The  gn.atest  daii-rer  to 
tl«.'  patient  is  that  of  severe  hemorrhage.  .Vftcr  stn.ivinir  a  nnmhcr  of 
these  eases  one  gets  the  impression,  howvcr,  that  the  metrorrhagia  is  not 
a  resnlt  of  tlu  .  njsion  of  the  fetus,  l,„t  ...ther  that  the  hemorrhage 
occurs  heaiiLso  the  (list>ase  luis  assiim..!  u  "  lien.orrhagi,.  ..han.cter." 

VARIATIONS  IN  THE  COURSE  AND  MANIFESTATIONS 
OF  THE  DISEASE. 

The  e.ul  of  the  f,.l,ril..  p,.rio,l  in  almost  evcrv  ca.se  marks  th.  end  of 
the  (li-ease. 


RELAPSES  AND  RECURRENCES. 
Kolapses  and  nvi,rren..es,  so  ..ommon  in  tvphold,  are  of  the  .rpeatost 
ranty  m  typhi..,.  a..oth,.r  among  the  many  points  of  rcseml.lance  he.ween 
this  d.-,.aseand  the  acute  exaMthemat,.|.  Althond.  some  anth.irs,  among 
>'■'■".  Man.lliev.  ..lain,  ,„  |„,„  „|.„,,,„,  ,.„,^_|„,^.^  frc<,nentlv.  th..v  have 
ail.Hl  to  pnHJu..,.  any  po-i,ive  proof  for  tluMr  statements,  for  it  i's  al.s.^ 
Intely  nccs-ary  to  ex,.|ii.h.  with  certainty  other  complin.tions  or  s,.,,n,.Is 
:-s  caus..s  ot  the  ntiew,.!  fc^■cr,  .-ind  to  -how  that  the  ri-,.  in  t..m|H.rat 
wa-   immediately  foII.,w(,l   l.y  a  s.vomi  apparanee  of  the  chara.-teri 


r.isli. 


lire 
-tic 


■X'  -I 


552 


Twin's  ii:\i:/;. 


Munl,i>„„  l,i,„M.|rM..v..r  .-:,u  .„  „u,|„„l,I,-,|  rase  of  n.lnpM.  „r  r..,.urrtMK.e 


"•'i    ^au    1    ,M>c.    Mi|(i    (.\,.||     i'.u.'li.-iiriii      >,.,.    Miircl,iM)i 


ri'CCIItly,    'rildilMil.     (.; 

;;'"l''""Min.|     ,nnr,.   ,|.J,,    lrM>,.„r„M,in„l.,..,l,vlM|.>,„,',vronlMn,n„::^.HM, 

...-.>   M,   tl,..     K,.„1,.M     I'c-^w   Ho>,mal.      1     .nvs.-ir    Uny.   1'  ol,s..rv,ui.,„.   ,„ 


r.i/;/.i7/o.v.s  /.v  ri,ri:sE  am,  ,i/.i.%//7;.sy  i  v/ow  of  i>i.si-:.\sk  :,:,:>, 

rrprrl    thai.   I    l„lu-v.-.  aiv    um,!,,,,!,!.-!   ca.-r- ,,f  rrlMp-..,  l„il  I  uill   also  a.M 
IliMl   1    l„.|i,v.-   lUr  raso   i„    I...  aiminalnus.  win,  I,  i>  |,r,,vi.|    l,y  llu^  la,|    i1,mI 


i5    .; 


l.otl,   ,.f  tluMu   n,.,.unv.l   i„    l.sT.s   ,„„„„..  a  v.tv  .„,all    niunluT  of  patients, 
«h,l.   n,   l.s,!l  „,.  taile.1  iooU^-rve  ai.vtl  '-g  in  the  km  resen.hling  a  nh.i^e 


or  ji  iiHurreiice. 


ij.'f:;- 


■>!'-A^y\ 


554 


7177/r.s  I i:\i:n. 


I..'    TM  ....SO  «Ms  tl,Ml  ,.|  a  laLnnT,  iwrntv  ..six  yoar.  „r  npo.  wh.,.  al'LT  a 

.•V...      , „„•,„„,    u-a.,.,l    ,a.-..   „r  ,v,,l,u..   H.v.T   ..tm „■„,-    l,v    Iv.s.s.    ..,„..r,. 

' ,":  •;"-''-•'•"<• IM-Mv..,,,....,..!,   .hu.      Mur,\u;  ,,.;ri.„l   lu-   «  ' 

>  ■-•   tn..n    t..vcr.    I„>    h.>n|H.ra-.ir..   I,..,,,-   „H,aiU    .m,I r,„al,      KLvn.   .lav 

.■l,a,laM,,,l,,.r..|,,la,,,hl,..,,.,,,,,..,-aM.n.n.,   ra|,i,ll . . -Tl,..  .,,i.,.,„,  «  1m,I,        i 

."    Il|'   >l„r,l   ,lay  ,„,!,.  .I,.s,.a...   ,1,,^,  «a.- a  ,li.M„„,.  ,|,„mi:I,   nan  v  7      . 

M>.   .M.|,„i,M,^  tl...   ,l,„>al   >ur.a,.>  of,!...   1.,,.  ,|,,    ^.J-m,.,,.   laNT   in  t 

|l.r,,.,n,  a   ,.,...  n a  1   ,..,.,; a„..„.      <  „,   ,1,..  .i.U „...  ....^^al, 

i.M^.r  .   allh.M.I,    ,,n,  ,ar„.,l.  „,,,   ,„„   „.„|„   i„„.rr,M„,,|. 

",:';:;';  •"■'•"", '•77"  ""■  '■";'  '"""■  •"•'""'^•^-  ""-^  ■""'  ""• '-  'i''■'-^' 


II  nciirri'ii 


"I   .itt.Klv  ..1   tv|,,„s   „,ark,..l    i,v  .xtninelv  hijrh   t..n:|.fralur,..  llu  tev.-r  H.|l 
...tarrlMl  .,.1,    ,,„„  „1   ,1,..  lannx  .,..  ur<^ixun-  .lis.a.vo  ,.f  nnv   , s,.,m,,„.,.  |,a.l 

i: :  ::i:"  •  ='""'■"■■ ;  -7- ':'-  *'-"-i  i-  ••-  un,,...  -i.un,,,' li,:  ,i, 

■        '•  --'''I   -•■     .!..■   th„  ,   ,lay   nm.r  ,|,e  ...l.i.l..,,...   of  fev.r   U.e 


•""", ^"'  "  ''''11  =""'  ''"■  I.'Mi|..Talur,:af:aiM  l,..,-aM  tn'ri,.,..  rearlmi.r   ;i!.o(. 

....    ....  ..vemnf:  ot   ,l,a,   ,lav       Tl,.-  t..n,,K.,atu.-..  ....„,i„„..,l  ....lerau.lv  l.i.h 

-r  tl,.  ,„,,.„  ,lav..  a„.l  .1,..,,  .^nulually  l....a„  „.  fall  l.v  .li.Min,.t  Iv.k  the 

lyn,    „t   ,k.f..rv....,.,.n..,.   1,..,,,.^  ■■n,„,,l..,...l    l,y  ,l,e  „i,„l,   .fav.      ()„   ,|,,   v..,v 


VARlATIOr  '  EN  THE  COURSE. 

Tho  ro„r.o  of  ,vplH>s  f;.v,.r  is  siily.-.t  to  v.ry  wi.l,.  variations,  wl,irh 
nt  ,l.f!,.rrMt  t,n„.s  a..,i  on  tl,o  st-vnfrth  of  ol.s.Tvations  ol.taii.r.l  i„  .litfer- 
Hit  ..|ml(.mi<.~  luvo  vvvvWv,\  a  -ivat  va.-i..tv  of  ,iiU;.re„t  nan.c^ 

Older  Nomenclature.-TJM.s.  it  was  f  ,r,m.rlv  tl».  ,.,isio,„  ,o  a,.ply 

v,..-.o„s  nanirs  to  ihr  ,|i„.:,s..,  ,i..,„.„.linnr  o„  tl.,.  [.rnminrn,.,.  of  sv,„,,to,m 
n.fcniM..  I,,  .Iclinit..  i:.-ni.|.~  of  ,,|.j,r:,,js  or  to  sin;:!,,  oi-friins. 

'I'l.c  trnn   fill,!,,,..    ,irrr„..„>,   or   ti/plnis    a>a.n,;,.y  was  appli,.,!    lo  ..ascs 
w.il,   ...iiiMially  s,.v..r,.  ,„.,vo„.   .nanifo-talions,  mi,.1,   a«  .l.ii.-Jun.,  roma, 
siili-iihns  tcndiimni,  and  (.arplioloirv. 

WUru    io-s   of  -tn.ML'tl,    witn    .....nliar    weak.,...-    a.„l    ;,     t,.nd,.M..v    to 

'•'.11^.|.-..    .......1;-   its   appranii,..,.  ,.arly.  ||„.    ras,.  was    ..ali..,I    /,//./,„..   „i„j-o. 

'nl,nunn,r„s:      r„i,hu.  .hiscnirnr,,.  was  .iia-no,ni  wl,..„  dia.TJaa  -r  trn.. 
<ly~..nt..n-    Mrnpto„,s    i;,,.,,,,..!    a    pron.iii,.nt    f,,,t.iiv,    wliii..    tl I.lcr 


i;«12^<OlLt 


VAnrinoss  i\  <;,i-i:sr.    \\i,  m\mii:st \tioss  ,,f  i>isi:.>s/:.  r,:,-, 

Kri;:li-li  an.l  |,,-li  |.l,y.i,.iMii>  iKiriimlMrly  wrrc  likrlv  i,,  .,„,,k  of 
/:)/./>Hs  r„t,n;l,nlis  ulirn  the  timc.ijs  rncml.n.iu-  of  tlir  air-|,;,-si;:..s 
«irlv  l).-,.:inu.  it.v..lv...|  aii.l  |.r,-..nt..|  ih,.  ,„,,st  .•.„„pi,.,i.,u-.  -vr..|.tom,. 
Tli.„.  iuiii.....t..  vvhi.li  a  lar;:..  nnn.lur  that  an..,.  i„  a  -iniilar  maniicr 
niiulit  Im.  adcl.Ml,  havr  littl.'  tiiHrc  than  a  lii-t,.ri<.  int.n.^t  at  il...  ,,n-.,.„i 
.lay.  Tlir  :ip|».araii<v-  an.l  niai.it;.stati.m~  of  tlic  .li-,,,^..  an-  ,a|.al.l..  ..f 
an  infinite  niinilMr  ,,f  cinihiiiatinns  an.l  tli,.  nnnilxT  uf  .■lini.al  i.i.turis 
is  s,,  var-i,.,l  that  il  ran  l«.  n.^itlirr  jn>tilial.l,.  n..r  usolnl  to  .lignilV  in.li- 
vidua!  forms  liy  -|w(ia!  naino. 

**"   •' "'•■•■   •':"'<•'   i'    i-  "l"  'Mii.'li   [.ni.ti.'al   litiiitv,   not  to  say  of 

=''''"'""■   ' ''^^''S  f'>r:ipr.,|HT  nn.lrr.tan.linjr  of  thr  .liM-a.-o  t..   lorn,  a 

cavi-M  ,.>tin.ato  of  tlu-  .liff.r.Mi.v-   in   severity  an.l  .luration,  an.l   .i~v  a 
nomenclature  l)a>c«l  on   fh,..,.  ,|i(riT.'nccs. 

We  will  tirst  .•onsi.l.r  in  this  ronn.rtion  .-ases  of  mil.l  .l..>rr(v,  csises 
..f  >h..rt  .luration,  an.l  ahortiv..  <.a>.s,  whi.l,  in  typhus  fever,  as  in  all 
aente   infectious  .liseuses,   phiy  a   very   ini|K)rtant   /•.;/,■. 

Th.>  manifestations  an.l  the  e.Mirse  of  these  forms  are  Mil.j.vt  to 
reniarkahle  variati.ms,  an.l  the  conditions  on  whi.^h  th.^v  ,|c|M.n.l  are 
even  yt  pnieti,.aily  unknown.  The  fr<-.,uenev  of  their  o<<'nrr..n..e  vari.-s 
with  the  time  an.l  variety  of  the  ..pide.ni..,  an.l  also  mav  varv  during 
.htlen.nt  [xTiods  of  the  sam,-  ..pLJ-mio.  .\.s  the  epi.lemie  spen.l.  its 
fon^e,  a  r..markal.le  inerea.-e  in  the  nun.her  ,,f  milder  ease,s  is  often 
ohserved. 

I  think  we  are  justiti...l,  in  studying  the  reasons  f.r  this  phenomenon 
t..  a.ssume  a  gnulnal  ,leer,.ase  in  th..  str,.ntrth  ..f  the  morl.ifie  a.'.>nt  as 
the  ..p,d.>n..e  progresses:  .,r  it  n>ay  he  asstun.Kl  that  afW  niost^of  the 
in.l.vi.luals  spcially  pr<..li>,H,s,Ml  to  th..  ,lis«ise  have  I.een  attack.Hl 
those  who  are  less  .lispoM.I  f.  it  also  b.-eome  affe.-ted.  We  ..annot  hot.^ 
to  gam  a  true  nn.lerstan.ling  of  these  e..n.liti,.ns  until  we  U,,rn  nion.  of 
the  nature  ..f  the  typhus  fever  poison,  an.l  until  su.'h  genend  .pustions 
a.s  pnMlisposition  an.l  immimity  hav.^  I.eeu  furth.T  .du.'i.late.!. 

If  we  examine  ...ascs  .,f  short  .lunition  an.l  .-ases  of  mil.l  .le.rree 
mor..  «.refully,  we  fin.l  tlmt  a  short  atta.'k  is  l.v  no  -ueans  n.vessaHlv 
ehara..t..n.e,l  l.y  a  mil.l  course.  A  ,-ase  may  he  „,il,|  from  h,.,d.u,in.r  to 
eu.l,  without  heing  at  all  short  in  .luration;  an.l,  ..onv..rs,.|v.  .,ls,^s^.f 
short,  or  ..v..n  very  .hort,  .luration  not  infn>.|uentlv  pres.-nt  a  ..ruv 
Hmi.'al  picture,  not  .mly  .luring  th,.  a.^tiv,.  course  of  the  .liseasc^  j.ut 
even  until  the  heginning  of  deferveseen.'e. 

Cases  of  Mild  Degree,  Well-marked  Cases,  and  Cases 

of  Short  Duration.-As  cmpan.l  with  the  fre<pien,.v  of  mil.l  forms 
of   typhoid   fever  with   relativly   low   temp..nUures   kn..wn  as  "...stric 


.l.tli 


/•)  /7/rs    //I/./; 


mm 


f.\<r        ,„•    ■.„„„■„,„     n.v.r."    ;,m;,I„^„„-    ,.;,-...    „f    tvplMi,     n.v,.r     ar. 

'li-im,tK    I „„„.„,.       I\,„    -,„l,    .„-..-   ,.-    ,„,|    n,,„llv    i„    ,v..v.Tv 

""'"""  ■■'">    """-"^'1  .•,„„, ,|„,„i ,.   ,,..n„aM,nt   iiiiurv  to  ll„.  1„..,1,|,  ,,f 

tl'"  in.hv,.l,ul,  >„M.-iinu.~.  at    I,..m,  run  tl„ir  .■,„„•-.■  „i,|,  |,i.|,  r.-vr  a,„l 

1  "I  r, -|„,,|i|irij,r|\    -r\(.n'   i|i-- 
liiiliaricc-     ,,('     tlic     :r.  ii.nil 
'■"'i'lili"ii.         In      an\      ([li- 
•  liriiir,    li..u(\ir.   ca-i-    will 
l>f    ii|,-,.r\c<|    in    wliicli    ill,. 
5      ili-ta>c    ruii~    it>   iniir^r    in 
I      llif  M-nal  tiiiir   -('nun    Cnp- 
I      III  n    til  MMfiiciri    ila\-.    of 
*      rviii    loDi^vr — witliont   once 
-      in:init;-iinir     :in     nniiMially 
;      lii;.'li    icinpt  nitnri'. 
'^  I  llt'^r    niiiil  ia~i -i  irciHT- 

5      ,illy    ilo    not    l)ri.rin    w  itli    a 
V      ili-iimt      cliill.        AftiT     a 
:      |iiiio,|     duiiiii.'    wliiili     tlic 
r      p.-itiinl   niniphiins  of  diiHv 
y       liiliiijrs,     the      liin|)(Tatiii-(" 
~'      ii-<-   (.'railnallv,    liv    mh'ccs- 
l      -ivc   .-.ti|.-,    Ml   tliat    it    may 
S      Hot       rcaih       its       iiliimato 
Uvljn     liclorr     the     I'onnli 
"   -      ilay    of    the     ili-ca-c.      Ac- 
loriliiijrly,  tlif   initial  -yinp- 

toiil lirailarlli',     liarKarlic, 

J  voniitini:,  I'll'. — arc  al-o 
li-»  -I'NiiT,  anil  in  nianv 
[latiriit-  till'  ininil  fcinain-; 
i-li-.ir  fviu  ill  till'  cMiiini,' 
ami  ilniiii;:  the  immIii.  '|'|„. 
-nli-ri|ni'nt  (■oiir-c  ,,t'  tlic 
(c\iT  i-  ot'i<n  iri-i'iriilar, 
v^iiii  inarkcil  irnii---ions 
iinil  intirini  — ion-  (  l'"ii^-.  il  |  |, 


111   tiir    IHTiocl    o|'   ilclrrv,.-,  , 


iiic  i-cii'iin  |.roti-arli'il.      Tli,'  iimI-c,  particii- 


lirly  in  men.  is  mud,  I,-.  Civiincii  than  in  tlic -cvrc  ca--,  ami  invvmncii 
it  nsiiallv  remains  of  o,„„|  volnm,.  ami  tm.-ion  tliroii^r||,,iit. 

I  have  an  iinpiv-Hon  that  -picnic  cnlarjremcnt  i,  1,--  ficpieni  incases 


r  I/.7  I /7o.\.N  /.v  ((,1  i:.\i     [\i>  .u.iMi  i..>i  I  nn.w  ,,■    /</>/  in/. 


<>(■  llii-    MimI,     irid   thai    llic    ni-li    :il- 
III   a    iiiiiiiIm  r  uf  tin 


II-"    I-.   a-   a    rule,    li—    \\,||    nniUcd. 
M'  ca.-o  <aiarrli.il    I  irMi;:iii- and   trailiciilnniiiliiiis 


Diiv  ..(  Ih.  ,lii 


urrc   lH,tli  ,.arlv  and  inarkrd  f.-aliiro,  and  llirincl  tlic   in..st   .nn-i.iciu 
clianiitcn-tic-  ot'  il.r  clinical  |)ictiirc. 


Ill  additii 


11  ti)  tlicsc  ca-c^  111'  ••  cata 


rrlial  t\  iiliir- 


I    h 


ohscrvo  •_'  case 
last 


'h 


Ki   (icca-imi    ir) 


inictcrizcd  hy  a  relatively  low  Imt   |iriptra<ted   i 


e\cr. 


istiiij,'  III    I    ca>e  as   Icpii^r  as   twentv-two  da 


lys,  III  wliieli   syinjpt(>iii>  ol 


iu'iiuirriiaf^io  ncphri.is  wen'  at  first 


pletoly  aftor  the  end   of  def 


very  conspieMoiis,  and  vanislie:!  enm- 


ervoseence.      In  the  case  in  which  the  (ever 


r:*' 


r-\ 


•AA.' 


"1^1 


'♦V 


Vv 


.■'-r. 


AiilA 


MICROCOPY    RtSOtUTION    TEST    CHART 

ANSI  und  ISO  TEST  CHART  No    2 


1.0 


l.i 


li.  IIM 


1:3  2 


1.25   il.4 


m 

112.2 
[2.0 

1.8 
1.6 


^     .APPLIED  IIVMGE     Inc 


''6)    *e2  -  0500  -  Phon« 


tm 


ryriiis  j-j:\j:j;. 


hi-tol  t\V(iiI_v-t\V(i  days  the  ni.-li  was  so  scaiitv  and  hi-tod  mi  sIkhI  a  tiiric 
that  the  diaj.'iii»is  iiii;,dit  lia\f  rtiiiaiiu'd  doiihti'iil  if  the  cxatiiiiiation  had 
hfcii  at  all  >ii|)crlicial. 

\\  I'  ciiiiic  iiixt  lc>  till'  ca.-cs  cliaractcri/cd  liv  short  duratinii  and  a 
mill!  cciiir.-c.  The  iiiuiliid  iihi'iiDMK'iia  iti  many  of  thoc  casi's  arc  even 
iiiildcr  than  in  the  lurcj^dinj;  jrriiu|).  The  s|)!cnic  cidari^cnicnt  and  liio 
cinptiiin  art'  mily  very  sparinirly  d(V('|i)|)(  i],  and  the  di>('a.-('  ends  witliin 
ii'iiin  live  to  ciirht  days,  'i'his  variety  is  illustrated  in  Kijx.  'i"»  (coniparc 
also  Fig.  (Wi). 

'I'liese  are  the  eases  in  whieli  tlio  eharaeteri>tie  eliiii«d  pietnre  is  often 
so  disf;ui.-e<l  as  to  he  (|uite  nnreeofrni/ahle.  It'  tliey  arc  the  first  <ines 
dnrinf:  an  e|)idemie,  the  diaj,'nosis  is  |)raetieally  impp-sihle,  and  even 
(hirinjr  the  hi  i^ht,  or  toward  the  end  ot"  the  cjiideniie,  tlie  diajrnosis  will 
depend  laifjely  on  the  history  and  the  <letetiniiialion  of  tVe(|nent  or  iiili- 
iiiate  relations  with  undonhted  eases  ot'  fy]ihns  t'ever.  I  cannot  ae^rec 
with  (iries>inL''cr  ami  other  authors  who  maintain  tiiat  tlie  rash,  or  at 
lea.~t  tlie  cliaraetciisiic  rose()|ou>  eruption,  is  constantly  alisent  in  tlicse 
ea»es,  which,  hv  the  older  antiiors,  were  nsnally  desii^Miated  t'chrictda. 
1  have  seen  patidits  ot'  this  kind  cxliihit  a  well- inarkeii  and  clianic- 
teii>tic  eruption  wliieii  lastitl  even  lonp'r  than  the  f'ciirile  period  when 
tiie  latter  was  very  siiort. 

Abortive  Cases. — It  will  lie  well,  t'or  iiraciieal  rca.-ons,  to  make 
a  di-tinction  iictween  the  ca>es  of  '• /'.  /</■/.<  r.ririiflii  iiinlirii  /rris  if  A'r/.wnyK/  " 
jn>t  de-erihed  and  tllo^e  in  which,  after  a  severe  onset  and  clinical 
course,  defervoeciicc  make-  it>  appeai-ance  une.\pect(Klly  early.  The 
term  "  abortive  tvpliu- "  may  with    pro|iriety  he   ajiplicd  to   such   cases. 

In  the  cases  n'  tin-  clas<  it  lia|>pens  more  fr<'(|Uently  than  in  those 
of  "  fehri  exantliematica  Icvis.-inia,"  althonjrh  l)y  no  means  con-tantly, 
that  the  liij^licst  temperature — after  a  violent  initial  chill — is  reached 
within  from  twenty-four  to  thirty-six  hours  or  even  earlier.  After  this 
time  the  fenipci-atnre  usually  ])ersists  for  -evci-al  days  at  ii-  inaNimum, 
ill  the  tlirm  of  a  continiii'd  fever  or  continued  remittent  fever-,  less  t're- 
(|iientlv  it  i-  (piitc  irretriilar.  The  teniperature.  which  may  lie  extremely 
hitrli.  then  falls  liy  ilistinct  <'ri-i-  {  Fiir-  'i*i)  la-ting  lint  a  few  lionis,  and 
remains  normal. 

The  condition  of  the  patient  in  tlic<e  firm-  i-  often  extremely  alari<i- 
iiit:  fir  -everal  days  or  even  until  ju-t  lief m-  the  lieirimiinir  of  deferves- 
cence ;  after  initial  phenomena  of  great  lolenee  the  patients  pre-eiit 
marke<l    lielietnde.    ]irofiinnl    pro-tralion,    and    even    furious   delirium. 

Till ndition  of  the  -pleen  varie-  greatly.      In  >ome  case-  I  have  .-ecu 

a    marked    enlargement;   in   otlicr>   the  organ    was   not    swullen   at    all. 


VMUATioys  IS  (jornsi:  jm>  MAMi-i.yrATioy.s  uf  disease. 


.■f.")'.! 


Till'  ruse-spots  ill  ahortivi'  i'urms  are,  as  •■  rule,  few  in  minilxT  and  ia>t 
Imt  a  slioi-t  tini.',  altli(.ujr|i  sonictinu's  a  nnnilxr  of  lluiii  unilcii;^ 
pft.vliial  tiMii.t;,niiati(jn  nr  |KUc!ua'  may  (lovc!(.|)  ind.'i.cn.lcntU  ammii: 
the  rose-pots.  Tlie  ern])tion  of  larjje  inaeiiles  tliat  has  Ween  rel'.rrt>.l  to 
ai)|.tar~  to  he  more  eoinmon  in  abortive  eases  than  in  \\ell-Miarive<l 
forms  of  the  disease;  and  aiiotlier  point  that  seems  to  m<'  worth  notin;: 
is   tlie   fre(iuent   apixaraiiee   of  iierpe>   tlieiah-   dnrin<r   tile   eri-is. 

Crave  piihiioiiary  eoniplieatioii-,  e>pe<ially  pneniiionia,  are  rare  in 
abortive  typlm.s  fever,  ahiioiijrii  sometimes  larynjxitis  and  bronchitis,  as 
oceasionaliy  ooonrs  in  eases  of  tiie  "  febris  exantliematiea  levissima," 
form   a  ]>rominent   fwiture  of  tlie  disease. 

Ill  a  few  ea-es  I  observed  an   nnusiialiy  .-low  pulse  uf  go.^l  volume 


Fl'..   fi".— TnilMr,  ai;ia  mncluiii.     Almrtive  Ciurse 


Uiw  piilso  cvi'li  iliirint'  tlu'  IVIirili'  inTicd. 


and  tension,  sometimes  not  exeee<Iin<r  from  80  to  100  in  the  eveiiiiij:. 
This  jihenoiiieiioii  in  itself  is  a  g<M)d  pro<rnostie  sijrn,  and  jiistities  the 
hope  that  the  course  of  the  disease  may  be  abortive  ( Fi«rs.  <1<;  and  <ii  ). 

The  condition  of  the  kidiiey.s  in  the  abortive  forms  is  usually  fiood. 
Slight  degrees  of  albuminuria  may  oeeiir  :  marked  excretion  of  albumin 
with  blocnl  [  saw  in  only  1  case,  and  that  was  oi'  mtlicr  long  duration,  so 
that  it  could  hardly  be  called  a  distinctly  abortive  case.  T  give  the 
temperature-chart  of  this  case  in  Fig.  (IS,  as  it  shows  not  only  the  cour-e 
of  the  temperature,  but  also  the  oeeurrenee  and  signiticanet-  of  a  rela- 
tively slow  pulse. 

These  case-,  it  neinl  hardly  be  said,  form  the  transition  between 
abortive  cases  and  those;  of  moder.ite  severity  ending  in  rec'overy  m 
which   the  duration   is  not  abridtrcd. 


;jt;() 


TV  I'll  IS  I  i:\i:n. 


li.-  \*    r 


'VT- 


■<  ..t;-,.'\ 


■  •  is     -  ■■■! 


Su  till-  w.'  have  <lisciis.-i"(l  la.-cs  in  wliicli,  as  \vc  Imvc  sen,  a  (liaj."in>is 
vnuUl  lie  mad.'  will,  (vrlaiiily,  or  at  !.aM  uitli  a  fair  .L -nv  of  prohalMlil.v, 
(-p.ciallv  if  tiny  wcr.'  iiiiilcr  ol.-i  rvaiion  ti.r  a  Mitliciciitly  \i>u<:  tiiiw. 
In   ..vcrv  cpidcniif,   liuw.  \  (.r,  .-in.ially   wluii    it    is  at   it<   lui^rlit    and 


t  >\vard  till'  end.  caM'-  <.(vur  that  cannot  he  diaiinosed  witli  <'iTt;dnty  and 
in  whi.'li  til."  interpretation  will  he  jrreatly  dependent  on  the  ]H)int  of 
view  of  the  ohserver.  In  these  eas..s  tlu'  fvvvr  lasts  hut  a  short  time 
an<l   examination   fails,  to  disclose  any  ])ositive  sijrns  of  typhus,  Mich  as 


yii:i.\ri').\s  i.\  curnsi-:  a.\i>  MAMriisiATioss  of  disfasi-: 


:,(J1 


tlif  clianu'UTistic  r:i>li,  altlimiirh,  at  tlir  r-aiiic  titiic,  otIuT  «li.-taM.-  can  Ik.- 
jxi^itivclv  fxchidid,  anil  tlic  lii-t<>r_v  ^l|M^v-  that  tlic  individual-  liavr  liad 
close    rclaticins   willi    ly|iliiis    I'cvtr   patient-. 

Some  (if  tiie-e  ea>e>  nii^'lit  with  ji'Tleet  justice  he  ealleil  •'Ji'hrix  cxdii- 
thcmnticd  siiir  iSdiilhcmnti ,"  in  imitation  uf  ana!o;_'nus  eatie-  that  (H'ciir 
in  variola  and  scarli't  ll'ver. 

This  form  is  inentione<l  in  tlie  writinirs  of  other  authors,  e-peciaily 
the  more  recent  nn(  -,  amoUL'  whom  1  may  name  Koseu-tein  and  Naunyn  ; 
the  former  claim-  to  liave  ohser\<  d  it  (|uite  Iniiuently. 

Finally,  we  have  ,i  ;rrou|)  of  mo-t  iierplexin;:  ea-es,  liatHiufr  :dl 
attemj.ts  at  diajiUo-i-.  individuals  who  have  for  a  lonjx  time  heeii 
ex|>o-ed  to  the  intlueuce-  of  the  typhu-  liver  poi-oii  .levelop  a  condition 
of  ijeneral  depre— ion,  los-  of  a|i|ietite,  in-omnia,  pain  in  thi'  liiad  and 
limlis,  iin;;iii^r  in  the  ears,  hleedinj:  at  the  no-e,  and  irrey;ular  fehrile 
di-tnrhaiK'e-  lastinj,'  for  days  or  even  weeU-.  without  ever  exhihiting 
anv  pronoimce<l  -yin|)toms  of  the  disea-e.  I'hy-ician-,  ward  attendants, 
and  other  persons  whose  duties  hrinjr  them  in  contact  with  typhus  fever 
patients  are  particularly  |)rone  to  ilevelop  this  condition,  and  it  is  ;i 
notcworthv  fact  that  they  nsnally  recover  very  (piickly  as  simhi  as  they 
are  remove<l  from  their  nnfavorahle  surronndinjrs.  .Fai|not  lias  deserihed 
tills  condition,  which  he  i"alls  '•  tt/iiliixtitinn  '>  jxtlt)'  tlaxf"  a  term  that 
sutlii'iently  descrihes  his  interpretation. 

Ambulatory  Cases. — In  this  connection  the  i|uestioii  comes  up 
whether  walking  eases  occur  in  ty|)hns,  as  in  ty])hiiid,  fever.  Some  of 
mv  own  observations,  1  believe,  point  to  the  oeeurrence  of  siieh  eases, 
if  not  with  certaint\,  at  least  witii  a  fair  dc^rre<'  of  probability,  and 
anioiijr  other  authors  I  may  (|note  Becher  and  Passaner,'  in  whose 
writin^r^  similar  statements  may   be  fotnid. 

The  IVe([Uency  of  mild  and  very  mild  ea-es  ;dso  appears  to  vary  with 
the  peri<Hl  and  the  individual  epidemic,  '{'he  fact  tliat  -■  nic  authors  do 
not  mention  them  doe-  not  indicate  that  they  did  not  occur,  but  rtither 
that  tile  clinical  material  was  ob-ervwl  under  peculiar  circumstances. 

It  is  worth  iiotinji  that  children  a]>pear  to  be  more  frequently 
attacked  by  this  fmn  of  the  disease  than  do  adults  ((Uriessinjror,  Wyss), 
and  that  the  milder  forms  olh'n  become  more  |>revalent  amonj;  adiilt'^ 
toward  the  end  of  the  epidemic,  ])artieuiarly  amonjr  individuals  who, 
owinix  to  favorable  -urroundijij.rs  and  {food  |ihysical  condition,  may  be 
as-mncd  to  |Missess  a  ;rreater  resistance  to  the  poi-oii. 

It  is  liiffieult  at  tills  time  to  irive  any  fijrurcs  in  rofiard  to  the  froqiieiiey 
of  cases  of  short  <liiratic)ii.      AinoiiLT   .'147   cases   in   ^tllahit  analv/.eil    liv  mv 


ii.ri ! 


'  IScrlin.  /dm.   lC..,-//,vis,-/ir.,  ISOK. 


3(1 


.1-,.  /[:i^-'^.:^. 


562 


TYriiis  I  i:vi:n. 


assistant.  Salomon,  '24  wtTc  trie  iV t'cvir  oij  froiii  llii'  scvfiitli  to  the  ninth 

(Imv.  It  will  !»■  sffi.  tliiTi'lorf.  llial  \m'  failol  to -ret  the  niil<l<st  and  >liortcsl 
casi;;,  tor  till'  fini|ili'  rca.»on  liial  tiny  ran-ly  i-ntt-r  llie  hos|iital.  anil  arc  mmh 
practicallv  oulv  in  privalt  praiiii'i-.  it  i-  ralliur  inlircstinL'  tlial  .Miirdiison. 
who  lia.-  L'ivi-n  .-o  lari fill  a  ilrM-npiion  nt'  \W  ili^'a.-r.  rail>  to  say  aiiyihin^' 
alidut  tills  ola.-s  of  casfs.  iii-  statistics  in  rcL'anl  to  the  dnralion  of  tiie 
(liseiise  lio  not  include  any  ca>c>  of  |cs<  than  one  week'.-  iluiation.  Ainoni; 
.■).■;  patients,  lie  liad  o  in  whom  the  di.-case  ein'ed  on  the  elLrhlii  or  ninth  day. 

RELATIONS  TO.  AND  COEXISTENCE  WITH,  OTHER  DISEASES. 
Acute  Exanthemata. — 'i'lie  iim-t  interc-tin^'  i-claiioti  i-  tliat 
wliicli  exist-  lietwcen  tNpliii-  te\'ef  and  tlie  acute  exaiitlieiiiala,  to  which 
it  i-  -o  tiearlv  related.  it  may  lie  -tated  tliat  ty|ihii-  i'ever  jn-oliaMy 
(loe>  not  occ.ir  -imiiltaiicoMsly  with  tiie  acute  exaiitlicmata,  altl,ou>;h 
i.-nlated  in-tance-  of  such  iK'cnrreiice  arc  ineiitioiicd  in  tlie  literatuiT. 
'{"lie  repoHs  are    not    eon\  iiieiiiL'.  however,  and    the    liirciroitiir   statein«>nt 

must  hold  o-,„.d  imtil  re  po-itive  ea^cs  are  reported. 

.Murchi-ou,  who  <l(ie-  not  liituself  a]>pcar  to  have  tnet  with  the  eoin- 
plieatioii  under  (liMiis-ioii,  eivcs  i'.arallicr  and    Hucliaiian  as  liis  auihori- 

tic-  till-  the  -imultaiK -  occurrence  of  small-po\  and  typhus  fever. 

JJai-allicr"-  -tatiiuent-  caiitiot  well  l)e  invc-liuatcd,  atid  i')Uch.itiaii's 
case,  the  lii>torv  of  which  Mur<liison  ipioies  in  full,  uiKiiicstioiialiiy 
admits  ot'  more   than   one   iiiter|)retation. 

Ill  rcirard  to  the  coexi-teucc  of  typhii-  and  scarlet  fever  wc  al-o 
iacl<  ivlial)le  iiiforinatioii,  and  tlie  statement-  in  re<:;iT(i  to  the  compli- 
cation with  tiieaslcs  are  more  than  uiU'ertain,  liccaiisc.  as  wc  have  seen, 
lioth  disease-  (iiiritiL''  tln'ii'  initial  st;iire  pre-ent  the  symptoms  of  c.m- 
iunetival  atid  iifonchial  catarrh,  and  liecausc  the  Tuoi-liilliform  fash  of 
typlnis  t;  ver  i-  sometimes  iiidistiniriiislial)le  troin  :i  fu<,Mcious  eruption 
<pf  measles. 

We  mil-t.  liowever,  clearly  di-tiiiiruisli  helwceii  actual  coexistence 
and  a  rajiiil  or  <'ven  immediate  -ueec-sioii  of  typhus  f-ver  and  the  acute 
exanthemat-i.  'i'hat  iutlvtion  with  one  of  the  a<'Ute  exauthernatti  may 
oc(air  diirini:  convale-ceiice  or  even  towaril  the  eu<l  of  deti'rvesi'ctice  in 
typhii- :  and,  conver-eh,  that  individual-  recoveriiiu'  from  -earlatin.i. 
iMasle-,  or  variola,  ma\,  owin^  to  -.im<'  uid'ortunale  accident,  iinme- 
diatelv   contract    tvphn-    fe\'er   cannot    Ke  denied. 

I  niav  nicnlioii  the  case  of  a  youni'  man.  eiL'hteen  years  of  ajrc,  in  whoMi 
a  well-iuarki'd  rash,  which  for  the  most  part  immediately  hecame  pctecliial. 
develo|)e(l  while  the  skiii  was  still  undoriri)in<r  the  typi<-al  lamellar  des'|na- 
ni.ation  of  scarlet  fever.  He  had  a  severe  attack  of  typhus  fever  which 
ended  in  recovery.  .Murehison.  out  of  a  total  of  7  cases  of  lypliUs  follow- 
ini:  imniediatelv  "upeii  si'arlet  i'ever.  twice  saw  the  disease  develop  during 
the   period   of  dewiuamatiou. 


r.i/.7.i /'/o.v.v  i.\  loinsi:  .wn  .u.i.\ii-i:.srMi<).\s  ni   iiisiasi:.  'yw\ 
Other  Acute  Infectious  Diseases. — A  numlicr  of  ili.>c  arc 

••;i|)m1i1i'  cit'  liiiiij^  ((imlpiiicil  willi  typliii-  lever  diiriii;.'  tlie  lieii.'lit  "t  the 
I'eliiile  -l;ii^e  (If  tiiwanl  tlie  eiiil,  (ir  diirinj;  tlie  l)eirii"iin<j  of  (■onvalo- 
eeiii'e. 

Tliis  applies  |iarii<iilarl_v  to  pyemia  and  septic  processes 
eaii-eil   l>v  >ti-e|)U)eoeii   and   >ta|ili_vloeo(ei,  i-ptiially  er_vsi|)elas. 

Tlie  oeeiirreii.e  of  fibrinous  pneumonia,  due  to  the  action  of 
the  Fraiiivel-\Veieli.-ell)anm  liacilhi-,  <hiriiiir  the  febrile  periixl  of  typliiis 
fever  lias  already  heeii  referred  to  as  a  distiiietly  fre(jnerit  and  very 
f^rave  eoiuplieation. 

In  this  eoiineetion  aeiite  tnliereiilosis,  espcH-ially  aCUte  miliary 
tuberculosis,  is  >|)oken  of  by  all  authorities.  It  may  develop  in  any 
staf^e  of  tvpinis  fescr,  but  occurs  ino-t  frei|Uently  toward  the  end  of  the 
fel)ril(>  ]>erio(l  or  duriuLT  <oiivalesciiicc.  I  have  ob-erved  this  eorn])li- 
eatioii  .")  tinier.  <  )ue  ca-c,  occuiiiuir  in  a  younir  woman  tweiity-tlu'ee 
vears  of  ajre,  |)re-cnted  a  typical  picture  ot'  aciiti-  basilar  lueninjritis,  the 
tiisl  svmptoms  ap|)cariiitr  toward  the  c  iid  of  the  second  week  ot'  an 
attack   of  tvphns   le\(r   with   modeiatcly   severe  on>et. 

The  relation  between  tyi)hiis  fevrr  and  relapsing  fever  is  both 
interesting^  and  important  from  a  projrno^tie  standpoint.  That  the  dis- 
Oitses  niav  cocxi>t  is  bevond  all  dotibt.  It  is  probable  that  the  stajrt' 
iA'  incubation  of  tv|ihus  fever  may  bcLnii  dm-in^  the  continuance  of  an 
existing  rclapsin<r  fever;  whereas,  conversely,  the  s])irillum  ot'  rela]>sin)r 
fever  |)robablv  <lo(~  not  become  pathoLTciiic  in  the  body  of  a  typhus 
fever    patient,  or   at    lea-t    such   an    oecurreiice    is   extremely  f.ire. 

I  have  already  iriveii  a  brief  accomit.  with  the  tetii|)erature-ciirve  (Fig. 
.")7i,  of  a  case.  iil>served  in  Moaliil  in  \X~\^.  nf  typhus  iiiuiieiHatidy  I'ullnw- 
iiii:  an  attack  of  relapsiiii:  lever.  Similar  I'oiiiplicatioiis  of  typluis  and 
relapsiiiir  fever  had  been  repeatedly  obi-erved  liefore  that  lime.  »Sueli  ca.scs 
are  prohalilv  not  rare  when  the  two  diseases  are  epi<leriiic  at  tlu'  same  time. 
The  comhinatiiiii  was  not  unknown  to  ( iriessiiiirer  ;  and  Hermann  '  mentions 
not  ordv  the  onset  of  typhus  one  to  three  weeks  after  an  attack  of  relapsiiiir 
fevi'r,  l)Ut  also  cases  in  whici\  tvplius  fever  appeared  to  follow  ilire<lly  upon 
the  latter  di>casc.  S])itz  '  reports  that  in  the  Mreslau  typhus  epidemic  of 
1«7!>  several  rclap.siuir  fever  patients,  after  they  had  been  in  the  lios[)ital 
from  three  to  live  week>  without  coiiiiuir  in  contact  with  tyjihus  fever  ca.-cs, 
were  attai'kcd  bv  the  disease,  t  (ne  of  these  cases  closely  resendiles  ours  in 
the  absence  of  any  interval  hetweiMi  the  cml  of  the  relapHini:  fever  attack 
and  the  bc;.'inninir  of  typhus.  Seelii.'er''  also  reports  4  instances  of  typhus 
infection  durinir  an  attack  of  rela[)sini;  fever,  and  1!'  ea.«es  in  which  typhus 
declared  itself  a  short  time  alt;'r  the  patient  had  recovered  from  relapsing 
fever. 


.  ;•  I  ' 


ii 
i   ;.  I 


I'rtrrxh.  me'l.    \V,.rl,rns.-l,r. .   ISTi',,  =  Dr„fs,-/i.  .ir,-h.  f.  klin.  Mfl..   lid.  xxvi. 

^  r.n-r,,,.  kliru    U;.r/irns,-/:r..   1 8SH,   Nos.  :,] .  ;V_'. 


?*ri' 


664 


TV  I'll  IS  I  i.vi.n. 


Tliai  typlius  iiiul  typhoid  fever  .-m  .xir-t  tu;.'<ili<  r  -..in-  t..  mo 
v.TV  iiui-rold-lr,  ..rat  l.a-t  .,,,,..1  to  ,|iu-linii.  I  •nlortunMlMy,  M,an>  of 
tli.^l^ifincnts  on  tlii-  -ul.j,-.'l  arc  of  little  valif.  So,,,,.  ,,f  tl,.„,  .laf 
f,on.  a  tin,.,  wl,.'.,  tl,.'  tvs..  .liMa-..>  won-  i,..t  .■arcf.iily  .li-lii.-ui-li.'.l. 
whii..    many   ..tl,.i-   aiitolaf   tl...  .li,-.'..v.Ty    an.l    stij.ly   of  ll.f    KL.Ttl, 

ba.•illu^. 

I  am  .-[iiallv  ili.-in.liii..l  t.>  a.v.|,t  tli.'  iiiimcr..ii^ -t;it.imnt,~  111  iviranl 
to  tl.r  .•...■Ni-t.'i>..'  ..f  typlm.  liv.r  an.l  diphtheria.  Dipl.tluri.' 
.•haiiu'.-,  ill  tl,..  -implf  aiKit..mi..  .-.hm.,  arc,  .,f  ...iirM.,  kii.,wn  to  every 
,.x|Kii,ii.'.Hl  .>K-.rv.r,  Kiit  it  iviuain>  f..r  l.a.'l.rioloLM.-  investigations  in 
fntur..  .i.i.lcmi.s  t..  -l,.>w  wl,..tl,er  ti,.-  .lump^  wer  .lepen.!  on  the 
L.'.tller  ha.iUns  an.l   .an  tlieref..re  l.e    interpreted   as  <lipl,tlieri<'   in   the 

eti.>loiri<'  >en-<'. 

The  e.,exist.nee  .,f  dysentery  an.l  tyi-hns  fever  I  .'.m-Ller  very 
pn.l.al.l.^.      I    nn>.lf  saw    l'   .'ases    in    whi.h   .Kxnt.ri,'   manif.-iati..ns, 

with  mue.,ns  an."',  i.l ly  ^t.H.l-  an.l  s..paiati..n  ..f  th.>  inf>tinal   nni.-.ms 

memhranc  in  -hre.1-,  f..rm..l  pr..minent  -ympt.mi^  .>r  th.'  .li-eas... 

Miir.'hi^.>n  reirar.ls  .iyseiit.ry  a>  a  rare  .•.,mpli.'ati..n,  ..eeiirrin^'  with 
anv  .l.'L'ree  ..f  friipieney  only  in  .•.rtain  ei>i.iemi.'s.  Thiis,  diirin;:  the 
Crinicim  war  th.^  tw..  diseases  ,.xiM...|  side  i.y  -i.le,  an.l  am..njr  the 
Fren.'li  s.il.liers,  who  livisl  ami.!  nnfivoral.le  hypeni.' .■on.liti.ms,  eases 
w.T..   ..l.-erve.l   in    whi.-h    the   same   in.Jivi.lual  was   attaeke.1    hy    both 

di>ea.-.'s. 

Acute  articular  rheumatism  an.l  typhus  fever  may  U-  e.>ni- 
l.in.'.l  in  the  sense  that  the  latter  .-an  l.e  a.-.inin'.l  'Im-injr  the  exiMen.'e 
.,f  a  polvarthritis.  An  instructive  case  in  th.is  re-]).'-'!  is  ,hat  .,f  a  man. 
thirty  vears  of  atre,  in  tlu' ( 'harite  II..spital,  wh.,  l..-cam.'  infe-'ted  .hiring 
the  f.l.rile  stage  .4"  an  a.iite  arti.  iilar  rh<Miniatisni,  an.l  was  a.lmitt.^.1  to 
the  la/aivlt.,  in  M<.al.it  with  a  sev.Tc  case  ..f  tyj.lms,  .•..mpli.'ati.l  I.y 
hem.>rrhai:ii'   n.'phritis. 

The  Relations  between  Typhus  and  Chronic  Affections. 
—The  relati..ns  Letwcn  typhus  an.l  other  .li^<'ases,  espc.aally  chr..nie 
eon.liti..ns,   have  l..'..n    r.peatedly  r.i'.ii-e<l   t.,. 

I  d..  n..t  b.Oieve  that  any  .liscas.'  atr..r.ls  a  pn.tection  against  tyj.l.ns 
f.ver.  On  tl,c  .M.ntraiy.  n.-t  a  f.^w  chroni.-  .■..n.liti..ns  .hara.'t.^iize.l  I.y 
malnntriti.m  a.i.l  l..-s  ..f  str.iigth  s.^'in  t..  h.^ightin  the  prc.lisposili.m  of 

the   in.liviiinal. 

Am..ng  sn.'h  .•..n.liti.ms  chronic  alcoholism  i-  .-pcciallv  t..  he 
m..nti..n.K[  X..t  ..nlv  arc  a  gr.-at  nmnl..T  ..<'  alc..h..li.-  foun.l  am..ng 
the  .ia-.-  usually  atta.'k...!  I.y  the  .li-..ase.  l.ut  it  is  a  fact  that  sueli 
indiviihials  are  actually    m..re   prone  t mtract  it. 


'  ) 

'7  ■' 

\ 

I 

r.i/.7.i77o.v.s  i.\  cnriisi:  .\.\i)  .u.i.v//' /•>/'. I'/vo.v.s  ar  ihskasi:.  .m;.') 

'I'll,.  ,<mrM'  of  ihc  ill.-fusc  u^miic-i  ul-o  ;i  ?^|Kvi:il  clianictcr  in  :il<M>licilic 
siil.j.rt:- ;  it  i-  <li.-iiiictl.v  tiiorc  -tv.rc  iiii.l  i-  more  likily  to  tiTiuiiuUe 
t;it:i'.ly  tliaii  in  jmth.iis  iVir  tVuiii  tlie  vi(T.  'I'll,  re  i-  ii'>  <l')iil)t  tlial  it 
l:irj;clv  explains  tlio  fait,  (IctcriiiiiuKl  \>\  iiiiiiuTuiis  statistics,  tliat  the 
iimrtaliiv   i,-.   Iowit   in   \M>inon   tiiaii   in   imii.  _ 

S.nu' "f  tlif  «arlit>t  and  tno-t  marked  nuinifestati..lis  of  tlie  disease 
in  aleulic.lie-  are  seen  in  the  iierv(in>  >\>tein,  in  the  heart,  and  in  the 
'idneys.  (irave  di>tnrl)an'<s  of  eunseiousness  make  tlieir  aiiivaranee 
during'  iheverv  tir>t  day-  :  violent,  even  tiirion-,  delirium,  often  followed 
hv  a  transition  into  eoina.  iiartienlarly  the  ominous  form  of  eoina-vitrij. 
l'rotraeto<l  eases  are  partietdarly  likely  to  a-sume  the  form  known  as 
••  atiixo-iidynamie." 

In  chronic  alcoholic  -nl.j.fts  the  i)nlse  l.ecomes  :darini!i>rly  smnll  vor>- 
early  in  the  di-ease,  the  t.'nsioii  .liminishe-,  and  the  rate  is  j-reatly 
incrcasixl.  There  is  hut  little  doiihi  that  this  condition  of  the  puise  is 
due  ([uitc  as  nnich  to  vasomotor  paralysis  as  to  weakness  of  the  hci\rt- 

muscle. 

The  kidnevs  in  alcoholic  patient-  rcjiularly  show  e-arly  and  .severe 
involvement.  In  some  cases  the  nephritis  tnanifests  itself  merely  by 
marked  allminimiria  and  the  presence  of  simiilc  hyaline  .'asts  in  the 
urine.  Other  cases  present  symptoms  of  the  severe-t  forms  of  hem or- 
rha-rie  nephritis,  and  may  terminate  faUilly  at  the  en<l  of  the  first  or 
the    he^'iimiiig   of   the    second    week    with    ])ronounced    symptoms    of 

uremia. 

That  alcoholics  are  |>ar»icularlv  lialile  to  develo|)  hypost:itic  conire— 
tion  of  the  liinj^s  follows  lofjjically  from  what  has  heen  said  in  repird 
to  the  action  of  the  heart. 

Cases  with  chronic  tuberculous  d'sease  of  the  lungs  also 
fre(pieiitly  occurred  amonj;  the  material  uiuh-r  my  ohservation.  It  may 
he  said  with  certaintv  that  i»eisoiis  MitVcrinfr  from  this  condition  do  not 
esca])e  typhus  fever. 

The  development  of  nr,.neral  miliary  tul)erculo<i-.  or  an  acute  local 
extension  of  the  tuherculous  process  after  typhus  fever,  has  already 
been  refernHJ  to.  When  this  is  not  the  case,  ami  the  local  or  penend 
chaniies  arc  not  pronounced,  the  course  of  tiie  typhus  fever  a])jH'ars  to 
be  little  intluencc^l  l)y   the  clironic  tuberculosis. 


THE   EFFECT    OF    CONSTITUTION,   AGE,   AND   SEX. 
The  <'tVect  of  the  constitution — that  is  to  say,  the  jrenend   bodily 
condition   at    the  time  o^"   inflation — oi.   the  course  of   the  disca-e   lias 
fre<iuontlv   been   tonclu'd   upon.      It   has  been  stated   that   weak,  badly 


.')<i(i 


/ )  rills  1 1  \  1 1: 


fi 


lii>iiri-li<'ij.  ciciiiliiati'il  illili\'iilil;il-  air  |iai  linihulx  |ii'nii('  m  iic  atl:i(  kiii. 
ami  \M  iiia\  aiM  llial  -iirli  iiiiliv  iiliial-,  a-  a  nili  .  -Iinw  iliiriiiii-lci  i| 
|Mi\\ci>  'if  ri-~i-taiiic.  \'iL;ni-. Ill-,  ui  11-111  ■iiri-lii'il  iiiili\  iiliial-  \\\\\\  iioi mal 
lirart-.  arc  litlli  i  alilr  {<•  n-i-l  ihr  ilVcri-  .it'  l_\|iliii~  t'c\  ri,  jii-t  a-  tins 
lirllir    u  illi-laii.l    all    aniii     |iiiir(--(-. 

(  >ii  llii-iillur  liaiiil.  \  I  rv  ciiriiiilriil  |ir|--iiii-,  cmh  wIkm  nut  alinlinlic. 
w  illi-laiiil  till-  (li-ia-r  liaill_\  ,  jll-l  a-  llic.  i|i  i  l_\  |iliiiiil  li\  ii  ,  Tin  liiall 
ami  llic  va-<iiiiiiliir  ^v-lmi  In  llu-f  imlis  iijiial-  -iiiii  in  linij  c-iici'ial 
(lllli(llll\      in     Ic-i-t  in'_'    lllr    ill'crl-    lit'    llic    liisill. 

Sex,  y>i /•  M  ,  lino-  lint  a|i|Mir  tn  liaM'  am  Inalkcil  intliiciicc  on  tlic 
(■(illl-c  lit'  lllc  <li-(':lSC.  ll  i-  tlUr  tlial  in  all  l|iilillinr-  tllr  illtlllcllcc  nt 
-(•\  -liDW-  il-cll' tip  a  niarkiij  ili-jicr  in  tin  rifriini-tanrc  lliat  tin-  -f\  ti  it\ 
111' llic  ||i^(a-<■  and  lialiililv  to  dcalli  ai'i  ili-linclK  l:ii  atcr  in  nun  tliaii  in 
uiiincn,  lint  llic  caii-c  ul'  llii-  lie.  in  tlic  tact  that  umncn  afc  niiicli  li-- 
(■\|iii-cil  III  iiiita\  nralilc  iNlcnial  cnmlition- ;  I'nr.  lii-t,  tluv  arc  Ic--  cmi- 
-taiitK  cni:aL''cil  in  the  -tni;^e|c  tiif  c\i-tciiic  ;  ami  -icntiilK,  llicv  arc 
lint,  as  :i  rule,  adilictcd  tn  \  ice,  c.-]icciall\  that  nt    alen|inli-in. 

llic  (litl'crciicc-  ill  rcLranl  tn  age  arc  (li-tin<tl\  h --  markcil  in  t\|plin- 
than  in  l_\|iliniil  t'cvcr.  'I'hi^  will  lie  rc\eilei|  tn  later  in  -|ii  akinj.' nt  liic 
]>rujrnii.-is.  l'"ni'  the  |ire-<  nt  I  -hall  cniilhic  iiiv-ilt'  tn  a  tiw  remarks 
nil    the   inaiiitcslatinii-   n|'  tin'   ili-ea-e    in    iiitaiicy    ami    nhl   a^c. 

Typhus  Fever  in  Old  Age. — Tlic  i  licet  nt'  nl.j  ai:e  make-  it-cll' 
t'cit  as  carlv  as  llic  liirtieth  vear  :  after  the  lit'liith  \ear  it  lieennie-  sn 
iiii|)nrtaiit  a  f'aetnr  that  alnin-t  halt'  nt'  -iicli  [latieiit^  -neeiimli  tn  the 
(!isca-e. 

'rvplni-  I'evcr  ill  nlil  ai.'c  dues  iint  |ircseiit  a  tyjiical  clinical  |picliirc, 
Slleli  as  we  -ee  ill  senile  t_V|illiiid.  A  cnli-ideralilc  |irn|inrtin|i  lit'  the 
\:\\<Sf  inmilMr  nt'  \niiiiir  invalids  in  a  reduced  state  nt  health  wlin  arc 
altaekcij  liv  the  disease  liaxc  a  cnm]iaratiMly  low,  irrcu'niar  fcNcr  t'rnm 
the  lic^iniiiiiLr  "f  the  altai'k.  In  nldcr  |>ersnii-,  mi  the  nthcr  hand,  very 
liiuh  tcm|)eratnrc-  arc  tint,  accnrdiiiir  to  iiiv  exiicricncc,  liy  aii\  mcaii^ 
imcnminnn.  it  nia\  at  Ica-t  he  -aid  that  nldcr  |ier-niis  arc  Ic—  likely 
In  have  a  hijrli  cniitinnnn-  nr  remittent  I'lHitinnnn-  t"c\crnt'  Iniii:  diini- 
tinn,  and  present  rather  an  irrcirnlar  tcm|ieratnre-eiir\  e  uiih  marked 
clcvatiniis  and   dc|irc-siniis. 

On  the  nthcr  hand,  in  nld  |icn|ilc  the  di-casc  exerts  an  early  and 
|irnii(iiiiic<'d  influence  nil  the  cireiilatnrv  and  rcs|)iratnr\'  nriraii^.  PiiriiiL'' 
the  first  week  nt'  the  di-easc,  dnriiiir  even  the  tirst  days,  au'cd  individuals 
[in -(lit  svm|itniiis  111'  failiiiLT  circiilatinn  ;  the  |iul-i  i-  >tiiall.  ra])id.  aii<l 
nf  Invv  tcii-inii  ;  a  ninfiiiii:  |iiil-ciit'  12(1  aiid  an  cvcninir  |iul>c  nt"  1  H> 
are  mit  ai  all  nricnnimnii. 


I 


A-.iilil'iil  1  Mli-cJiil*  lici  i>\'  till-  i-.iriii:!'  Ui;iKlii--  :lllil  lllr  i-i 'll-l:illl 
.M-rlinincr  of -r\r|-c  r;il;iirll  cX  ti  111  I  i  11^;  inti  >  I  lii'  tillir  liriiticlliiilc-,  ii;.'i-<l 
nri'-oii-  ail'  iiioiii'  to  i|iM'l<>{>    IiiIiiiImi'    |iiiiniiiiiiii:i    anil    ~iiii|ili'  uc  ilitlalii- 

iiialms     li\  |iii-tatir    r lilinii-    in    llir    Iiiiil;-  vrry  larly    in    llic    ili-ia-r. 

liillainiiialiii'\  ili-ia-r^  nt'  llii  liiiii;-  tinNi  a  rliai':ii-Ii  ri-I ii-  ti'aliin-  nl' 
-iiiili'    l\|(liii-. 

'I'lli'  i-rlHral     llllAiPll~     -x-lrtll    111   iilil     |M  r-iill-    I'al'lx     iMrnlllr-     illMi'.Mil 

111  a  v.TN  iiiarkc<l  i-Mml.  Aillimi^li  llir  ililiriiiiii  i-  rani)  viol  nl  <<\- 
I'lii'iiiii-.    lull,    nilliir,  a--iiiiir~    a    iiinlliiiiiL:    tiiriii,    iiiliilinlr    i-    lik' ly  tu 

-iiow  il-ilf  iniirii  riiliir  ami    l"'<'' ■    iiiiU'li    iiiuri'  -i'\  ii-f  in  nld    |h  i -mi-. 

A-  I'Mi-K   a~  ilic-    iiiiiMIr,  <!!•  liiWMni    ilir  iikI,  111'  ilir  lir-i  \\c<k  iliT|i  <■ a 

i|iAilii|i-.  uiili  -iil.-iillii-  liiiiliiiiiiii    ami    iai-|ili<il";:>.       Tlir  t'lirtn    kimwii 

a-  •' ala\ii-ail\  iiaiiiii- "  i-  |iai'tii'iilarly  lialilr  I iiir  in  "lii  |»  i'mmi-,  imm 

wlicii  lliry  arc  iml  alinliiiii'-. 

A-  i-cuani-  llir  kiiliii'V-,  I  i-aiimit  -ay  tliat  1  lia\r  iml  uiili  imnc 
mirmriiii-  m-  iiiiiic  riiarki'l  i-a-i-  "f  iir|iliiiti>  in  -ciiilc  [.atiint-  than  in 
voimi;  ami  \i;iiirniis  mu-. 

Ontlic  iitlicr  liaml.  iliarrlit'M  ami  ily-cniiiir  atli'diiMi.- of  tlic  larp' 
iiit('.--tiiic  arc  <li-tiiirtly  imirc  (■iniinioii  in  nlii  a;ir  llian  in    ymitli. 

()\\in;r,  |)riil>al)lv,  tu  tiic  atiM|(liir  ciindiiinn  ol'  the  >kin,  tiic  typlins 
fcvtT  iii-li  xcins  to  appear  simifwliat  later  in  nld  peismw  an<l  tn  reaeli 
its  euinpicte  (li\  elnpinenl  inure  -liiwly.  ( )n  tli-'  nllier  liami,  iieim'rrliay:ie 
eliaiif^es  ill  the  nisli  ap|>ear  earlier  ami  are  pnine  to  lie  more  extensive. 
in  tlu'  matter  of  aiminiit  of  ra-h,  I  do  not  think  there  is  any  frri-at 
ditVerenee   lietweeli    old   aj;e   and   other    |Kriod>  of  life. 

Typhus  Fever  in  Childhood. — .Mthonj;h  the  disposition  to 
tvphiis  fever  is  not  less  in  <'liildhoiid  than  in  later  years,  if  we  disre- 
i.rard  the  p<riiHl  of  inl'ani'y,  the  actual  iiiimlier  of  eases  amoiijj  children 
is  conipamli^  .ly  smaller  than  amoiijr  adults.  This  is  due  to  t!ie  fact 
that  tvplins  fever  is  practically  coiithie<l  to  tlie  tloatinir  ]i<ipnlation  and 
tirtliose  anion^x  the  |H'niiaiient  residents  who  come  into  imme<liate  contact 
with  tiiem,  and  that  the  nnmticr  of  ciiildiiii  who  come  in  eontacl  with 
diseaseil  person-  i-  >niall  in  |iro])ortiiin  to  the  total  niimher  of  children 
in  the  coniniiinity. 

Of  the  eoiir-e  of  t\  jiliiis  fever  during'  ehihlhood  little  is  known. 
Kven  the  lielter  text-hooks  on  jiediatrio  pre-ent  littli'  nn  re  than  irenerd 
accounts  clo-ely  rescmliliiiLr  <lesi'riptions  ot'  the  disease  in  adults. 
Ilenoeh,  who  has  enjoved  a  wide  experience,  does  not  l>clicvc  that 
tiicre  is  aiiv  marked  ilitVcrence  hctwcen  tlic  course  of  the  di-^ease  in 
children   and    that   oli>erve<l    in    older   person-. 

One  tliinir.  however,  is  certain  :    the  co'irse  of  the  disease  in  children 


I 


iy^ 


.ir  •    ,1 


■  Vf 


&GH 


TV  I'll  1^  1 1  vii: 


i-  11-11. ill\  inniT  r;i|iii|  :iii(i  \i  i\  iiiiii'ii  iiiiiiT  III  \  oi:i  I  i|i  tli;iii  in  nliill-.  In 
llir  ulT.ll  ln;liiiril\  ,it'r;l-i-  iIk  ill-r.l-r  lil'lilinMli  -  In  twcill  till'  i  ii;lllli  ami 
ihr  IVM  lltli  ii:i\ .  A  iliiratluji  lit  iVniii  til'tri'li  l<i  -(Miilnii  il:i\ -,  M  In.  Ii  i- 
ii-ii;il  in  -i  \i  IT  ami  nmli  latily  ~i'\iri'  ra-i-  aimmi;  ailiill-,  i~  ili-l  iinl  h' 
mil'  ill  I'liililli I. 

'I'iial  till'  a\i  i'a:;r  .'ciii'-i'  ..t'  llir  iji-i-a-r  in  iliilillin.  m|  j-  milij  i-  ,|i,,uii 
li\  llic  ili'atli-i'Mli'  \\lii('ii  i-  In. in  -i  |ii'r..iit.  tn  7  \h  v  niil.  ;  w  In  na-  in 
ailnll-  il  i-  at   lia-t  .1  nr  ■'.  lihii'-,  and  in  old  a^r   M"  tiini"-,  a>  i;irat. 

It  i-  u.iftli\   nC  iiuti'  that    till'  M'Niriiy  nt'  llic   lii-ia-r   -Imu  -    niarkcil 

Viifiiili'iii-    ill    till'   (lilVrrnit    a-i'-  of   iliilill |.      'riu-   ^'Vifc-t    la-f-   ate 

I'niiml  in  vi'i-y  ynmi;;  cliiMi'in  up  to  tlic  littli  Mar;  tlir  mil.li'-t,  in  cliil- 
ilnii  lii'twii'ii  till  ii'iitli  .'Mill  tiriciiilli  Mat-,  wlicna-  iliilili'm  ImIwciii 
till'  ml;'!'-  lit  ti\i'  ami  Irii  vrar-  ui-rii|iy  an  iiiiriiiciliati'  |(ii-itii.ii  in  iihmiiI 
Id   till'  -I'M  rity   111'   tile  ili'-ia-r. 

'rii.'it  cliililfiii  iVmn  Dm'  in  liliiin  Maf-  ol'.-iLri'  Mil'  niiii'li  ii—  -i'M'ItK' 
iittai'kiKJ  i-i  jiaitly  iliii'  tn  llir  lait  that  llir  vital  lUiran-,  i-|icci:illv  the 
rifi'tihilnfy  -y-tiiii  ami  llir  iiiiinii  nrrxuii-  -\-li'in,  im-sc-s  tri'i'iitrl' 
|Mi\M'i'-  ill  fi  -i-tancr  til  till'  tii\iti-,  Mini  |iarll\  on  an'omit  of  tlir  roiii- 
iciiiitivi'ly  .|m;|  ihifMtioii  of  ihr  lii-ca-c  ami  tlir  irfiatir  iiiiitv  of  com- 
|ilii';itiiiii-. 

AiioiliiT  fai'tor  ill  tlu'   low  ilratii-iati'   i-   tlir    irnal    |ii'i'|Kinili'i-aiin'   of 

ca-r-  of  M'l-y   -lioft  iliinitioii,  or  ali-oliltily  iilioitivr    ra-i'-,  in   iliililli I. 

S'Vci'c  foriii-  of  till'  iIIh'iisc,  -iii'li  a>  ;iii'  oli-irv  nl  in  adult-,  i's|H'('i'ill\  tlir 
Ni-rallcii  fuliiiiiiatiiifr  tin-ius  coml.iiKii  with  loiiia-vi^il,  aii'  (li.-tiiirtlv  lafi' 
aiiioiijr  cliildfi'ii. 

Till'  lii'iriiiiiiiiir,  flio  cniirsc,  and  tlir  difrivi-iiiin'  of  the  fever  ill  well- 
iii:ii1<ih|  i-a-e-  do  not  |iri'-i'iit  any  in:irkii|  dilli'iiiice-  fnitii  ihose  oliHrveil 
in  adults.  Tlii'  ti'in|ii'fatiu-e-i'iii-\  e  tnay,  i'\eii  in  cliildieii,  attain  a  emi- 
.'-iilefalile  hi'i'.dit — 11  < '.  and  ovrf — and  inav,  duiiiiLr  the  fa-tiuinin, 
asfiinie  the   fofiii   of  a   continuiil   of   eiiiitiiiiiid    iiinittciit    feMr. 

Tile  ptil-t'  i-  alino-t  alway-  exti'eniely  fajiiil,  lint  ii-iiallv  fetain-*  a 
trill"!  ten-ion.      .Mai'inintr  eai-di.-ie  weakne--  oeein-s  alnm-t  exclii-iv  eU-  in 

<'llilill-i'll  who  ai-e  diliilit.'ltiil  fVolll  the  •  tVeet-  of  otlli'l-  ili-ea-1'S  111'  the 
niisefalile  eondilion-   .iiniii   whirh    ;ln.\-    IJm'. 

Altlioiiirh  fital  iiattilytie  -ym|)tiiin-  ai'e  eoni|iarati\  ely  fare,  iffitativc 
ner\iiiis  ])iieiii>mena  oeeiir  mofi.  ffei|Mi  iitK  and  .ire  inoi'e  \  iolint  in  ehil- 
di-eii  than  in  adult-  who  liad  lieeii  he.ilthv  1m Ci.fi'  liiiuir  allaekid  hy  the 
di-e.-i-e.  Cliildfen  .ife  iiinfi'  ffi'i|iii'ntl\  altai  1  ii'i  li\-  eiinvid>ion.-  dilfiiiLT 
the  ri-e  Of  at    ihe  helLdit   of   the  ii'\ef.  ami   the  delifinni,   restle<>ne-s,  ail'l 

!ini<ini--  ill  <e\-efi.  eases  aimiUL''  ehildreii  afe  i|uiti'  a-  marked  as  ai'e  the 
sjime  syiiijitoms  oliserviKl  in  adults. 


r.l/,7l//"\s    l\    mil-    •      Wh    1/ I  V//7  v/l /7'fVv    ,/     /i/s7;iv/-    .')6» 


< 'iiii|uiicii\  III-.  I  ir\  ihjil  I-,  :iii<l  r:il:irrli:ii  i.r.  iiicliii  i-  'mtiii-  i.  L;iil;irly 
illiil  'il'liii  :i--iimr  .li.uinin.  |  i  i|  m  .rl  ii  iii~  ill  iliilili'i  ii.  I  .■•liiil:ir  mihI  loliaf 
|>iniiiiiiiiii;i  :irc  ijiiiti'  ;is  I'ltiniiinii  ;i»  in  iiiliilt",  lull  li_\  [xi^ljilif  I'liii-nliilaliiin 
!•<  ili-tiiiclly  niiiiT  larr. 

rill  ,i|)|ic:iniiii>- '.f  llir  l\|iliii~  irii|i'iMii  i-  |ir;iitii:ill\  llic>  -:iiiic  :i-  in 
adllll-  of  \(iilllili|l  and  liiidillr  :i;;i-.  Ill  cliilillfli,  :l-  in  M(lnlt-.  the 
aliiinilaiii'i'  nl'  tin-  i:i-li  iini|ni -limialily  \aii(-  widrly  in  ditliii  nl  i  |ii- 
dciiii,-.  and  llii~  i-  prnlialiK  tin-  ri'a-uii  tliat  cciiain  aiillini~  (( Iric^-inj^iT) 
r<i.rard  llic  ali-iiKi  i.r  -.intv  di\  rli«|iniriit  cfllic  iiii|itinii  a-  |ial'li(iilai-|y 
(•iiininipn  anicmi:'  iliildn  n.  In  ilic  -ainc  way  llif  ditlriTiit  i|iid(  inii's  vary 
widi  iv  in   n'jard  to  |Mii(|ii:d    lraii~liiiiiialiiiii   "!'  lln'    in-"— |i"it-,  ImiiIi    in 

ciiildnn   and  in  adnll-,  altl i;li  llif  r.ivr   inn-torniali' I'  tlic   imnly 

niacnlar  ni-li  into  -inall  |.a|iul(  -  or  ,\(ii  ciniiialc  palrlio  a|i|«-ar>  to  lie 
soini'vvliat    iiKii'i'    lVr<|M('iil    ill    (liiMrcii    tliaii    in    adnlt~. 

('aniTinn  ori-.,  wliicli  ilainiMl  many  victim-  ainoii;_r  llic  cliildrcii 
during  ciiidrnin-  of  t'oinicr  liim-,  lia-  now  iiicoini'  -o  ran'  that  i'  may 
jiracliiallv  he   pa— i<l   oxer   in   -iliiici'. 

I>i'<Miliilii-  i-  di-timtlv  !(■—  t'rn|iiiiit  in  cliildnii  tlian  in  adnll-. 

DURATION  OF  THE  DISEASE  AND  PERIOD  OF  CONVALESCENCE. 

Ilavin^r  siitricicntiv  di-rii-^xij  llic  ahridj.fnl  and  aliortivc  furms,  I  uill 
now  diviitc  a  I'fw  para^n-aplis  to  tJR'  (incstion  ot"  the  dnratioii  of'  wcli- 
inarkctl  cases  ciKlinir  in  rccovcrv — tiiat  is,  tiic  jicriod  Itctwccii  tlic  Ix'^iii- 
llin;;  of  tlic  fever  and  tlie  end  ot'  defcrvc-cence. 

Duration. —  Tln'  di-crcpancy  amonir  ''k'  -tatemcnts  of  tiie  older 
authors  in  re;r:"^l  to  this  is  innch  ijreater  than  anioiiir  those  of  the  more 
nio<i<'rn  one-^,  proliaiilv  heeaiise  many  infection-  ili-ca-es,  es|)e<'ially 
tvphoid  and  nlap-iiiir  fever,  were  not  |)ropeily  distinjjuisluMl  from 
typhus  fever. 

The  \iews  ot'  modern  authors  cNhiliit  an  astonishinj;  unanimity. 
.Miiiost  all  s:ive  as  the  aveniijfe  the  shorter  duration  that  has  already  het'ii 
mciitione<l.  I'dr  a  well-marked  case  in  an  adult,  the  aveniy:e  duration 
ma\  lie  reLrarde<l  as  from  twelve  to  seventeen  da\-  ;  or,  to  he  even  more 
ex.ict,  I  should  >av  that  tlw  foiirte<'nth  dav,  accordin^r  to  my  experience, 
mo-t  t'nM|iieiitl\'  marks  the  tiid  of  ilet'cr\  e-ceiicc. 

Cases  in  which  the  fever  last-  lonj^rcr  than  the  eijrhteeiitli  day  are 
e()m])ar;itivelv  few  in  nuinlier,  while  an  imcomplicateil  case  in  whi<'h 
the  end  ot'  <let"ci\  (-ecnce  i-  delaye<!  Iieyond  the  tweiity-tirst  day.  in  my 
e.xpiiieiiec,  i-   di-tiiiiliv    e\ce|)tioiial. 

'i'lii-  diarp  limitation  and  the  strictly  cyclic  course  of  the  di-case  i\rc 
the  principal  points  ot'  dill'erence  iietwcen  typhus  and  tyi)hoid  t'ever. 


I 


lS^ 


^t'^ 


J 

■ 

•"II  iii'iirs  I  i:ii;i:. 

MiiitIiImmi  cmI.-ijNiI.'.I  lliMI  ill  ;iliiin>|  hall'  of  nil  lln'  ca.-i^  cHiviilcscnicc 
licLrii,  c.n  ilir  ihiiliMiiili  i.r  till  tiiurlcfiilli  (lily,  ami  in  iiidrclliaii  llircc-tliui-ili< 
"''  i'll    'ii-'^    lifUMTii    ihr    iliii-iciiiili    mikI    -ixicciilli   (lays.      TIicm>   iimiilMi-> 

u.rc  ..Llailinl   IVnin  an  analy-i-  i.f  ."i:;   ui iiiplii-alrd  cases.       In   ihr  r|,i(li  iiilc 

"I  l^i'.i.  ill  .Miialiil.  \\r  >iii-i(.cilc.|  ill  ilctiTiuiniiii;  rln-  iliii-aliiiii  ol'  tin- ilisca.su 
ill  L'!m;  ca^cs.  an. I  ..l.iainr.j  iIk'  |..l|,,uiii-  iiisiinri  i\  ,■  laMi'  : 

('iiii\  alc'scciici-  licjaii  at'lcr — 


7  .1m\-  in      I 


III 
II 
IJ 
|:; 


1  I  .lll\-  ill   IL'.- s 

i:.  :;:;     •• 

lii  >     •• 

17  ••      u;    " 

IS  •      14     •' 

II.  •■        '.I     •. 

L'll  ,       ■■ 


( iricssiii'jri-  .jiMs  ihr  liiiratinii  ,,\'  niildci-  rases  as  tVem  twelve  to  fdiirteen 
ilavs — that  nt  iju-  iiiajoniy  ,,{'  eases  as  Irmii  sixteen  tn  twenlv  .lay-,  .leiiiier 
lu  lieved  thai  uiii'. ini|ilieatei  1  i'a>es  run  tlieir  emirse  in  fn.ni  I'mirteeii  tntueiitv- 
tu.>  (lays  at  the  iiidsl.  liarallier  ealeuhite.l  ihe  a\erii>;e  .liifation  m  (1!'.^ 
eases,  ami  t'.iiiml  it   In  lie  tVniii  i,  ii  l.i  lueuiv-lw.i  ihns. 

Ill  illi.(iln|ili(ate<l  eases  COnv^icSCetlCe,  wluii  iiiit  iii-dtnictcd  hv 
sei|nel-.   |,roeee.ls   ir.n.      l-;i|.iilly   than     the  -everity   i.,"   llii'    elillieal     pietlirc 

!"!''  ill''  lili r   llic  IKitient-   iliinieilialel\    al'icr  the  end  nt'   iletiT\es- 

celiee  wmild   h.id  diie  l.i  e\|)e.  ,. 

Condition  of  the  Various  Organs  during  Convalescence. 

—  ,\ttt  r  a  MVei'e  or  ninderalely  -e\cre  attack  almost  all  patients,  althoiicli 
they  -ooii  liei;iii  to  feel  i|nite  e< miti irialilc.  are  pal',  dcliiliiated,  and 
ii-iially  very  iiiiieli  emaciated.  A  In--  ol'  tr,,in  Id  to  1 .")  priinids,  which 
in  a  di.ea-<-  la-tiiijr  only  IVoin  \\\i,  t,,  three  week-  cannot  he  i-e<rardc(l  as 
iiiinn-ider.-ilile,  i-  not  at  all  nncoiniiion.  in  -e\ere  ea-es  liutii  I  and 
other  .inthiiis'  ha-e  t'ri.<|ncm  l\  oh-erved.  even  diiriiii:  'lif  lirst  week 
atli  I-  the  disappe.-ir.anee  of  tlie  i(\cr.  an  additional  loss  of  troni  L'.',  to  ."> 
pound-,  till'  caii-c  ol'  which  we  can  at  pi'c-ciit  mcrel\    siiriiii-e. 

1  he  .j-rcalesl  |o-s  in  weiii-lil  occurs  naturally  during.'  the  lieiLdit  oC  the  liis- 
case.  Ill  niic  of  Icisciislein's  cases  a  los-  nf  10  pniinds  cicciiri-cd  hcluccii 
the  seventh  ami  ih,'  lifteenth  .lay  of  the  di.-ease.  In  another  the  same 
aimmiit  was  |..st  in  the  curse  of  f.mr  day.s.  I  myself  have  not  inf'reipK  ntlv 
seen  a  loss  of  from  7'  to  12  ponmls  in  tlie  course  of  from  five  to  seven  davs. 
and  ill  one  I'ase  a  loss  of  Iti]  poumls  lielueen  the  eighth  ami  the  thirteenth 
day  of  the  disea-c 

ill  a  (ew  ea-i  -,  where  the  attai'k  had  lieeii  verv  severe  and  pi-otniete<l 
:nid  the  jiatient-  were  previ.ni-ly  much  rediic,.ii  in  health,  i  had  occasion 
t.i  .ili-cr\!'  hydremic  conditions  with  edema  over  the  smaller  joints, 
aithoiiMli    till-   urine    wa-    free    I'roiii    alliiimin. 

'  ll.-iriiiMnii,   r.l.rJ,.  ,.,..i    |C,„./,o,-,V,,-..   1S7<;.   N,,.   l.i 


\ 


r  I/.7  ly/o.v.s  /.v  citinsi:  ami  M.iMi-i:sr.\ri'.'.\s  of  i)isi:.\si:.  :r,\ 

l)liriliir  tlir  lil-'  week  utter  (Idcl'XC'niii-c,  Miirictilllo  :i-  cui'ls'  ;i>  llic 
tliini  III'  liiurth,  ami  ii>ii:illy  lifl'mc  llic  tenth  <l,i\,  my  |i:itiei:t~  were,  a-  :i 
nilc^,  alliiHcil   In  oct    ii|i,  and,   it'  eiiM\ale~eeliee  \Va^    l.ot     ilili  i'i'll|)le(l,  lliev 

were  ii-iiall\'  I'eadv  to  l>e  (li.-i'liare'ed  and  ;^(i  haek  tn  wmk  al'tei'  three  td 
t'liiir    \\eeiv~. 

This  tllVoralile  e(im>e  ><['  eiiii\aie-eeilee,  while  jiartlv  due  to  the  -hurt 
(hiratiiiii  ut'  tlie  di~ea-e,  violent  a^  it  i~,  is  iini|nesiionahiy  inthieneed  to 
a  lare-e  extent  iiv  tlie  tiiet  that  the  oi-irair-  ot'  dijri...,tion  are  -n  little 
in\ol\ed  in  the  niorlml  [iroee--.  I''or  tin-  reaxm  '■omale-cents  in  tlii- 
di-ea-e,  more  tiirtunate  than  tho,-e  reeo\erinij;  tVom  t\]ihoid  lexci'.  ean 
lie  permitti'd  i'ullv  to  sili-lV  their  appetite,  wliii'h  retni'u,-.  heliire  or 
illM'inL;'    the    period    of  det'erve-eenee. 

In  -eVere  ease^,  i  \en  when  the  patient-  feel  quite  well,  the  |iul-e 
remain-  duiMnn'  the  first  or  even  the  seeoud  week  eoiniiaralivelv  >niall, 
-oft,  rapid,  and  -o  extraordinarily  -eii-iti\('  to  ixternal  conditions  that 
the  -lii^hte^t  proNoeation  may  iuduee  a  con-idei-aMe  althoii^di  trall^itorv 
li-e  in  the  fr<'i|Uenev.  On  the  other  hand,  in  some  ver\'  ii'chle  patients 
I  have  seen  a  remarkaiile  slowiiiir  of  the  pnl-e — iu  one  <a-e  down  to 
!<•  i)eats  a  minute — a<'eompanied  li\    jiron<iinieed  retardation.     How  this 

iu'ailveardia,    which    is    also    ol>-erved    iu    <itlier    inteelious    disease. 1 

nee<l  onlv  meuti<iu  tvphoid  fever  ami  diphtheria — i-  jirodueed  I  haxc 
heen   ipiite   uiialile   to   determine. 

The  lemperatui'e  u>uaily  tldls  below  the  phy-ioloiri"'  l<'\el  on  the  first 
afebrile  dav,  and  remains  sui)norinal  (hiiinu;  tile  first,  ami  often  part  of 
the  seeond,  week  of  eonvaleseeiiee.  It  may  be  extremely  low:  '\')°  or 
'.W  V.  in  the  inornin!.'',  with  a  very  >litrlit  I'veiiiufj:  ri-e,  i-  not  at  all  un- 
common. After  the  second  week  the  teuiperature-eurve  <rnidually 
returns   to   the  normal. 

Like  the  pul-c,  the  tempeniture  shows  a  marked  iu-tability  diM-ini.f 
the  fir-t  part  of  convalescence.  Physical  and  mental  disturbances,  -ii 
sliirht  as  practically  to  be  iniperccptil)le  to  a  licalthv  person,  often  brini; 
about  a  sudden  material  rise  lastini.''  a  short  time,  and  the  fever-curve 
becomes  a  faithful  re<'ord  of  any  little  di-turbanee-,  such  as  err<ir-  iu 
diet,  etc. 

.Mtlionyh  the  nerv<ins  system  in  well-markcii  cases  rctrularly  -hows 
•iuch  severe  implication,  the  di-turbanccs,  as  a  rule,  sub-ide  veiy  quickly. 
.V  |)er>istence  of  the  delirium,  e>p<'cially  duriuir  the  eveuinfr  hours,  beyond 
the  time  of  defervescence  i-  the  most  f're(|nent  of  these  persistinjr  di  — 
tnrbaiices.  J  have  seen  delirium  last  in  this  way  from  three  to  four 
(lavs,  and   even    until    the  end   of  the   fir-t    week   of   <'onvaleseence. 

In  the  iTfeat   majority  of  convalescents,  however,  the       rebi.d    fimc- 


i 


t^- 


^fr 


-A.; 


^•:; 


•"-  ryriirs  ii:\i:n. 

U<n\-  arc  n-t.md  .liiiiii-  tli,'  tir-i   ,l:,y~,  ,,lt,.„    iinnir.liatrly  alicr  ilic  ili- 
•'l'i"'ii-i>i<'''  "'■  iIk'   I'«v(  v.      Iii.livi.liial-  wli,,  (oiitiniir  f.,  hav  .Icliriiiin  in 

'' '■'■""'.^'-  'li"-i",~'  the  !iiv,  H.\v  ,lay„  ii~ualK  .xl.il.ii  ,l„n„jr  tj„.  .iavtiiiic 

a  <cilaiM    wraknrss  <.f  mental  a.tivit.v,  .-|>..<iall_v  a  l.,>s  uf  mymu'vy  for 
il.rniri-  ..vent,-.      Tlic  |.aticnt'>  ivccllc'ti..!.  of  his  illi„>s  i>  aliiin-t  aluay 
vci-v  liiiiitr<l  in  scvciv  nr  ni.Kl.iat.ly  .over,,  .a.-rs.    M,,st  jiatiHits  rcnicni- 
IxT   .>Mly    the   initial    sta^^tliat    i>,    tlio  days    .liirinir   uliicli    the    fv.r 
l.c-in-  to  rise.      Tlicy  ivtain  a  lively  rccillcction   of  the  apoiiics  of  that 

|)cri(Ml,  and  convalescent,  w  lio  have  ^n.ne  thi uli  an  attack  of  folapsinir 

or  typhoid  ■   v.T  affii-ni  that  the  initial   symptom-    in   those  .lisoases  are 
not  nearly  ,,.  had  as  they  are  in  typhns  fever.      '|-hese  initial  symjUoms 

ap|)ear  to  l,e  cniparahl ily  to  those  of  >niall-i>ox,  Jndfrinjr  from  what 

J    have   learned   from    typhus   convale-cent-  who  had   fi.rmerlv  ha<l   the 
tltrnier  (lisea>e. 

()i  the  other  hand,  the  p.riod  of  hyper|)yre.\ia  and  of  most  intense 
symptoiis  leaves  a  Mank  in  the  minds  (,f  the  majority  of  convales- 
cents from  a  severe  atta.'k.  A  few  of  them  may  roinemher  one  or  two 
panicnlarly  impre-Mvc  events  >n.Oi  as  haths,  the  vi>its  of  the  doctor 
and  his  ..\-aniinaiions  or  attempts  at  tli;rht  that  they  may  have  made 
and  the  mea-nres  adopted  to  prevent  their  repetition.  Others  renicial)er 
only  the  snlijects  of  their  e;irly  delirinni  antl  halhicinations,  and  of  tluse 
tJiey  retain  so  lively  a  recolle.'tion  that  they  contimie  to  he  tronhli^l  hy 
them  in  their  -hvpintr  and  wakinL--  moiiicnt~,  and  even  when  they  are 
fnlly  conscious  cannot  (piite  rid  theinselves  of  the  idea  that  there  must 
have  Keen  some  trnth  in  them.  When  it  i-  reinemhered  that  their 
hallu<ination-  freipiently  have  to  do  with  mo-t  nnii-nal  and  distrcs.-irKr 
situations  and  actions,  it  will  not  ho  dithcidt  to  nn<lerstjnid  that  thev 
may  he  a  .sonree  of  groat  distress  and  interfere  serioiislv  with  convales- 
(•<'nee. 

True  psyclioses  appear  to  he  rare  ilnriiiir  convalescence.  Mild  iiiplan- 
clinjia  and  hallucinations  are  sometimes  seen,  ami  even  mania  has  heen 
nltserved.^      Amoiiir  patients  ti-cated   in  Moaiiit  in  1.h7«  and   ]M7!I,  4  ea.'^es  of 

mental  distnrhnnce  occnrrc(l   dnrin;.'  convalesrence.      In  2  cases 1  in  Isy.s 

and  the  other  1  of  the  ;;  that  occurred  in  1S7!»— the  <iistnrhaiices  innne.li- 
Mlely  fnllowcd  the  end  of  defervescence.  One  ca.<e,  that  of  a  younjr  pri 
witii  delusions  of  persecution,  ended  in  recovery  after  ei^rht  day.s.  fn  the 
case  of  2  men,  the  psy<ho>i.  m^ih.  its  apiHarancc  later:  in  1  ca.se  toward  the 
end  of  c<invalescence  ;  in  ilie  other,  after  his  discharfre  from  the  hospital. 
The  former,  who  had  to  he  sent  to  the  insane  a.-;ylnm  on  account  of  viol.-nt 
mania,  exhihited  also  severe  auditory  hallucinations  that  were  undoul)t<dly 
due  to  the  fact  that  he  had  had  a  IkkI  otitis  media  with  perforation  of  the 
tymjvuiic  memhrane  durini.'  the  lieiLdit  of  his  illness. 


Sevei-e    oriranic    le-ions  of  the   centnd 


ners'ous  svstem   heinir,  as  has 


VMUATioys  i.\  ((irnsE  a.mi  M.i\iFi:.srAii<i\s  ni-  disease.  07:> 


Ixeii  Slid,  (|uitc  miciiniiiniii  diiiiii;:  tlic  lM)iilc  |itriiwl,  were  ninly  met 
with  ill  (li-tm'li;iii<',-  ciiiiliiiilin^r  duriiiu  or  cncii  :it'l(r  <'oiivali-rciirc. 
J~ii|;itc<l  ciiM-  of  |)uni|iic-ia  anil  iiftiiiplciiia  liavi',  Iiowcvlt,  I>ci'1i  oIim  rvcd 
in  ivcrv  ciiidciiiic.  No  ••a-i-  "I'  tiu'  ioniicr  have  ever  hccii  carct'iillv 
invi^tiuatcd  tillitr  clinifaily  or  aiiatoiiiically,  and  it  i-  not  tvtii  known 
wliicii  ot'  tiii'iii  arc  to  111-  attrilintrd  t'>  >|>iiial  and  whicli  to  ncnritic  di.-- 
tnriiaiHvs.  On  the  otiicr  liaii<l,  tiic  niori)id  anatomy  of  i\\v  ii(ini|ilri:ia- 
i-  nincii  licltcr  Uiiown.  Tliry  lia\r  Imcii  found  to  dipiiid  cillitr  on 
licnioiriiai:i-  into  tln'  l)rain->iil>.-taiRr  or  iiicniii|ii-,  or  on  l■nll)oli^nl  and 
tlironilio-i-. 

I'aralv-i- of  individual    inn-ilc<  or  ^'i |>~  of  muscles,  ur  of  a  -ini;lc 

t'xtrcinitv,  is  ipiitc  as  nnconimon  as  liciniiilcLda.  Of  tlic  niii.-clc~  in  tiic 
il|i|icr  extremity,  the  deltoid  appars  to  lie  mo-t  fre(|Uently  attaeke.1  :  on 
tic  trunk,  llie  Hiralii-  ma-nii-  ;  and  in  tlie  le.LS  the  extensor  nui-eh-  of 
the  tkiudi.  Whereas  heiiiiple-ia,  lieinir  due  to  an  orjranie  le-ioii,  is 
lisiiallv  verv  -low  to  di-apiiear  or  even  reinains  ineurahle,  ]>al-ie-  of 
individual  iiiUMle-,  as  a  rule,  disippear  iniieli  mure  <|uiekly,  -liowin^' 
that    lliev   are   |)rolial)ly  of  a  neurilie   nalui-e.  ^ 

A     inileli     more    ( niioii    event     than     pandy-is    dnriiiM:    emivales- 

eeiiee  is  neuraliii..,  uliieli  i~  often  very  di-tre--inir,  |)arfieiilarly  the 
iieiiraltiie  pains  in  the  to,-  and  sole-  ot'  the  feel  already  referreil  to. 
Thev  soinetiino  make  their  appearance  duriiiir  the  latter  part  of  the 
fehrile  |ierio(i.  and  per-ist  for  a  varialile  leii^'th  of  time  dnrinjr  convalc— 
cenee.  Althoiiirli  I  have  >ecn  them  disappear  hy  the  cud  of  the  first 
week,  I  have  also  known  them  to  last  two  or  three  weeks.  Anionu-  the 
rarer  liirms  of  neiiralixia  I  may  mention  indtria  of  the  snpni-orhital 
nerve,  which  appears  to  i)e  more  ohstinati'  than  the  oiIkt  forms  that 
ha\f  lieeii  mentioned.  One  of  oiir  c;iscs  was  still  sntVcrin^-  from  tiic 
condition  at  the  time  of  Lis  dischar^rc  Mention  may  als<i  he  made  of 
ncuraliria  in  the  distrihiition  of  the  linichial  |)h'xii<,  wliicli  assumes  a 
vciv  severe  form,  altlmuirh,    tortimatcly,    it   occurs  more   r.ircly. 

The  nervous  form  of  deafne-s  n<nallv  disappear-  with  the  fever,  hiif 
disturhauees  due  to  di-ease  of  the  middle  ear  or  other  j:nive  altt'i-ations 
are  likelv  to  he  iiku-c  oh-tinate  and  may  end  even  in  p<rmanent  deafness. 

TIr'  clian^''es  in  the  respiraturv  oririins,  which  so  fre(|iicntly  form  a 
distnrhinii  factor  in  tin  course  and  dniiition  of  convale-ccnco,  havo 
already  hecn  referred  to.  hut  we  must  once  more  consider  in  this  comiiH'- 
tion  the  frc(|ueiit  o<'currcnee  ot'  severe  altcralions  in  the  larynx  dnrintr 
nianv  ei)idemics.  Kxcn  after  the  fever  has  siihsided  they  nipiire  the 
most  careful  and  per-i-tent  treatment,  in  spite  of  whii'h  permanent 
aphonia   and   laryiij^'eal   steno-is  cannot  always  he  avoided. 


M^^ 


•"  '  lYfiiis  1  i:vii: 

Ainuii-   tlic  >rv.iv   (■..iii|,li,Mli,,ii~   of  .■unvalr-ccMcc   -lioiil.l    !>,■    ii„.|i- 
li"iM.I  ill,-  vai-hMi-  |.Miul.ni  and  ii,rr,,|i,-  piilinuiian  Mti;',-li,.M>  ,I,.|m  n-lin- 

""  l'i"'i'l-"'    |"ncl ,lriii~.      A-   lias  l».,.ii  >iair,l    in  anntluT   |.Lut.  i|i,  v 

"'■"■"  '•■"I  '"  I'unilrnl  ciru-iMn-,  and  Mil,jr.-|  ilic  paiirni  tu  all  tlw  ditli- 
<-iillic-   ami   .lan^^vr-    ,,|'  an    ini|iv<'nia   ii|).i'aliun. 

The  ..r-aii-  of  di-(-li..n    l.rin--  hnt    liiilc  involvc.l   ilnrin-    tlir  \u\.M 
'!'■  the  (li~ca-r,  iIhic  i~  hnt  -li-lit    intrrll'ivM.v  uiili   cMuah-cn-c   ti.   !,<• 

'■^"■•■''■''    ''■'""    '!'■"    'liim-lir.       I    niy-clf  .1 i    ivnimilMT  anv  ca^r  ,,f 

liii-  l^ilMl,  iail  Inmi  tli,.  iv|.,„-t>  ,,|-  -.■v.Tal  cpMcnii,-  it  api'...;!!--  ,|,at 
viui.'nt  vcniitiir^.  .MvniTini,'  attn-  the  in-otiun  ,,f  t;,.«l.  Iia.~  li.vn  oIp-.tn  ..I 
.lurin--  tlu'  tir~t  w,vk  aftrr  .Irlirv..  cn.v.  I  I,,w,.vrr,  as  a  iini,il),.i-  of 
rli.-c  ca-cs    pivM-nlcl   ■■iTiain    ~vni|.toni-  ivi;.|-al,I,.  to  llic  .vntral  iicnon- 

MMrni,  o.a-   rannot    avoid    tli,.    tlionuht  that  tlir   pi,,. „.n,,n    ina.v  have 

l)ccn   ui'  i-cntnii  oi'i^in. 

In  a   \vw  in-tanc-   patient-  \v,t<-   -.■,,, tly  tf.^nM,,!   ,liirii,o   ...nvalc- 
.VM.T  by  painfni  Mia.-cration  of  tl.,-  -nin- a-.i.iatcl  will,  l„.|i"oiTl,a-.-. 

IntlaiiiMiation  of  th,.  salivan   Ldaiid-,  d(.v(.|opin.r  ,lnnriy    the   frl.iil,' 
pci-iod    and    (-(.ntinninL;    dnrinu    .•..nval.-. .  :■■■,.   ,,r   ari-in-r    after  ti,e   rial 
of  the    lihiile    pei'iod.  o,vnr-  with    variahle    tr,|iien<y   ae.',,f,liiijr   to   th( 
p.Tiod  and  iiidiviilnal  epide.nie.       It  iiMially  tahe>  the  fbnn  of  imilal.ral 
parotitis,  or,  in  very  rare  ean-,   of  which    I    have    per-onalh    >eeii    hnt 

•  iiiflainniation    of  the   Hihlin-naj    -land-.       In  n.iv  te,l,l,-  pati.nl-  I 

have  met  with  -n|ipnrati( f  an  entire  sdivary  -land,  uiti,  ii<<'ro-i>  of 

tile  eoii!ii.eti\'e-ti->lle  stroma. 

riiaii-es  in  th,'  -kin  are  a  pariienlarly  friiitfnl   -onree  ,,f  di-iurhanee 

diiriiiLr  eonvaje nee.       Many  patiiiit-  continue  to  miIIIt  tiir  -onie  time 

atler  defervc-cenec  iVolil  -ail-relle  of  the  eai>,  tin-vrs,  toes,  tip  ol'  the 
no-,',  and  -kin  of  th,'  penis  and  -crotimi,  ari-iii-  diirinir  the  fihrile 
period.  In  L'  iii-tanee-  dnrin-  the  c|)idemie  of  IS7!I  \\v  were  dri\cn 
to    pertiirm    e\arlicnl.ition    of  iran-reiion-   toe-. 

Noma  and  iio-pital  ean-rene  l,.i\c  lii'coiiie  -o  rai-,'  that  tlie\-  need 
-eari'cly    lie    rei'koned    with   diiriii-   eonvalc-i'cnce. 

I>i  i-nl)itn-.  OH  in-  to  the  rel.iii\-ily  -hort  dnralioi,  ot'  the  di-ea-e.  i- 
coinp.ai-atively  ran',  and  i-  pr.aetic.ally  <i'eii  only  in  llie  iiio-l  .-exi'iv  ca-c-. 
Ii  iiia\-.  h<iwe\e)-,  a— nine  -neh  marked  proportion-  tli.al  \\v  cannot  lielicM^ 
it  to  he  entirely  due  to  pre— ure  .and  -oiliiiL;- of  the  allivted  parts,  Imt  it 
iiiii-t    he  a  — limed    ihal    trophic   ili-tnrliance-    in    addition   are  operati\c. 

It  would  appc.ir  that  the  firm  tli.it    I   have  di-ci-ihcd  i nnectioii  with 

m.anv   ca-e-   of    lyjihoid    fe\<.r,   and    de-i-nated    a-   -iiheiitaiieoii-    phlce- 

nioiioiis  deeiihitii-,  i-  al-o  colli p.i rat ively  i v  tri'i|ni.|ii  than  anv  other  in 

typhus  fi'vcr.      Without  |irodneinu''  :iny  iiiarke<l  pain  or  I'Veii  aii\'  aluior- 


rniK.sosis  AM)  MnniM.iry. 


575 


inal  >oii.'-;itiiiii,  ;i  miiiiilar,  \  illnui-li-n  il  uf  liliii-li-nd  (liMciluraiimi  nf 
till.'  -kill,  witli  Mi'irc  "Y  Ic—  I  \i(ii-i\i  inc|iir:iiii>n  awA  iiitiltnitioii  lA'  iIh- 
siiliciitaiicoii^  cellular  ti--iii',  (lc\cl(i|i>  ovir  tli<'  iialc-,  in  the  liiwcr  -acral 
rt'^xii'ii,  "I"  i\t'n  ill  the  (Icptlis  ot  tlic  tiiM  hclWfcii  the  inillock^.  Alter  :i 
tew  (lav^  line  cir  twu  small  i)|ieiiiiiM-  a|i|)ear  in  the  iiiidille  ,,'  tlie  di— 
eiiliircil  area  ami  ili<eliarire  a  lliiii,  ilirly-eolured  pii-.  if  .he  (i|)eiiii|Ms 
are  eiilar^^'eii  1>\  im-i^io'i  nr  the  ili-ea<e<l  |H)rlioii  ot'  the  -kin  iimlerjiees 
;;an;i:reiioiis  siippiiratiuii,  as  ik  t  iiitVi(|iiently  lia|i|>eiis,  a  snr])ii-inj;ly 
laii;e  (jMantitv  uf  |ius  eontaininLr  -lu'eils  uf  iieemii'-  tissue  is  e\aeiiate<i, 
anil  a  larj,''e  ea\  itv,  eMemliiii;  lii  all  ilireelion-  iieder  the  souiiil  -kin,  is 
reveale<l,  whieli,  altlioii;ili  it  rarely  exlinils  ileepir  than  the  iclhilar 
tissue,  may    take  a    Imiir   time   to   heal. 

The  iirdinarv  tiirm  nl' deeiiliiiiis  is  inure  nfteii  tiillnwed  l>v  a  deeper 
destrnetive  jn'iiecss  iioiim  mi  tn  iieem-is  ami  sei|iiestratiiin  of  himes, 
jiartieiilarly  in  the  saeriim  and  eneeyx,  and  al-o  in  the  sca|.iilu  and  tin- 
triiehanters. 

( 'I'l-elv  relateil  to  aeliial  deeiihitiis  there  neeiirs  tiirnneuliisi^  i)f  the 
;;luleal  rei^inii  and  adjniiiiiijr  |"irt!iins  of  the  hack.  This  eiiiii|ilieatiun, 
whieli  is  nut  verv  imeiimmon,  ufteli  oeeasioiis  tcreat  su!Verinii'  and  euii- 
sideralily  |iriitniets  the  period  of  eunv.ileseeiu-e.  ( )eeasionallv,  I  have 
also  met  with  t'nruneles  in  other  rei.'ioiis  or  ilistrilii;ted  over  the  entire 
liod\  . 

(  )liee  or  twiee  I   had  the  saiu,'  experieliee  1  hat   has  l/een  mentioned  hv 

other  author: of  ervsipi  las    tiillowin^  deeiihitns,    tiirnnele,  or  aliseess, 

hni,  f  n'tmialely,  I  never  lost  a  patient  from  this  eaiise. 

In  the  ease  ot'  a  \cry  fe\v  eonvaleseeiit  patients  we  had  a  trood  deal 
of  troiilile  w  itii  dilViise  phley,iiions  lie'_;inniiii.r  dnriiiLr  the  tilirile  period. 
I  lia\e  -eeii  tlieiii  on  the  anils  ami  on  the  -kin  ot'  the  ahdoiiien,  and 
believe  that  they  Were  dne  to  traumatism,  piohahlv  self-intlieted  injuries 
duriiii^  delirium.      (  )iie  of  tlie-e    patients   died    of  s,.ptieopyemia    in    the 

fourth     Wnk    of    lleti'l'Ve-eeliee. 

VERY    SEVERE    AND    FATAL  CASES.    PROGNOSIS    AND 

MORTALITY. 

1  he  eases  wiili  niodera!el\  severe  and  -exere  sNiiiptoms  in  tile  ordi- 
nary -en-e  haviiit:  hein  fullv  ili-eiissed  in  the  general  description  of  the 
I'liniial  picture,  tiir  which  thev  -upplicil  the  liasi-,  will  he  touched  u|k>ii 
hut  liiihtly  in  connection  with  |irocii(i»i,  ^md  inc.rtalitv'. 

In  this  scetidu  only  those  casi's  will  lie  particularly  mcutii  mil  that 
pre-ent  unusii.ally  severe  symptoiiis.  and  in  which  the  iiroiriio-is  i- 
e\i'eedill;rlx'    UlltilX  oralilc    or    alisolutelv    fat.il. 


/.  .■l.j;._..,:-i  ,. 


I 


£i-B 


iiii 


•Jl") 


/■)  fill  s  n:\i:i; 


'"  ""-  '•'^"-  "'•  '"■■'''■  '•'•'•'^lii'  '-aM-  ,,(•  v,i-v  -li,,rt  .liiratioi,.  cili.rs 
"(■  n-unl  l,„^tl,,  :„„1  ,.v,,,  -,„„.... f  ahiiMriiuMy  !,„,-  .liirati.,,..  all.  iiou- 
'V,  r.  cjuiracl-'n/,.]  I,v  iimiMiallv  lii::!,  HArr.  'I'Imv  aiv  il,,.  -,,-,, ill,.,| 
hyperpyretic  cases.  In  „„,-,  ,,t'  ll„  „,,  al'.,r  a  h„uI,.  viol,ni  rhill, 
''"■  l'"i|"'-aliirr  ii~,,  ill  a  -IimH  ii„„,  , „•  at  oi„.  Im,iii„|,  ,,rulil,  v.ia' 
-li-lit   iviiii-ion-,  I,,  ail   iinuMial   li.i-lil,    ||      uvwrn    11'      C.   |„in-  mIi, 'i, 

■'"■''"'■''    ""■'•■:■  -'"'I'   ' 'liii-n-    a-    .Mi-lv   a-    llir   vvnuvs  nf  tlir"-, ,| 

'"'  ''"■  '''''■''  ''■'>.  ■""I  'lii-  Irv.l  i.,  ,.,.  a  nil,,  MiaiiilaiiH.i  Cir  .lav-  or 
nnlil  th,.  -.v,„i,|  urrL,  ,.i,|„.r  uiij,  ,i,:„.L,.,|  niuniin-  iviiii-.i,,,,-  ,,r  u  ill, 
I.-  Ilian  ll,,.  |,l,vHnl,,:;i,.  ,l,ik  varia'iuii-.  Siirl,  ra-r-  ,,,rjv  ,Alnl,it 
mark..!  ,nlai-,  ,i„  „t  uf  ili,.  .,,1,,,,,  ;    ,„.,.,,~i„nalK  .  ,|i,.  nroar,  nia'v  JMrcii,. 

I'^''l''''''''   ^^''''   '!"■   li''-'    a •ll-: V  ..(•   th,.   IIKril..  -v,ii,,t,„nv'     Srs,,.. 

I'i'oiirliiii.  i-  „-i,allv  piVMiii  from  lli,-  li,.i:iii„iii^-.  Alun-  uilli  ll„. 
UMUM.alk  Indi  I.in|,..raliMv  tli.rc  aiv  oft,  ii  an  ,.\.v-Hvr  iiwiva-r  in  tli.. 
l)iil.-r-i-ati'  ami    an    alarniiiiL:-  <liniinnli<in    in    ihr   tm-ion. 

'"■''"'"-'  ■ill  tiir  ca-c^  th,.  crntrai  n.|-\,.n-  -.y-tcin  Imv.^iii,-  inv,,l\,.,| 
vci-v  ,arl\  :  Ni,,l,.„t  .l,liriiini  ,.n  tli,.  Iii--I  ,\,nini:.  rapiiilv  ,1,  v,i,,|,ino- 
liclirln.!,.,  u  ith  -iil-iiltn-  i.niliiiiini  an.l  carplhihiuv,  L^'in-'Mi  h,  tli.MJ.vpo"! 
'■"ina,  in  «|,i,.||  tli,.  inajority  ,,f  tl,,.  patient-  ,li,.  l„.tw,vn  the  ninth  ami 
rlcviMith  , lav-,  -,,in,  till!,-  aft, ran  c\,v- iv,.  pi-ca-v.ni,-  ri-,.  in  th,.  t,.in- 
|.cfatiiiv  (  Kij.-.  .-,!•).  1,1  a  -nialhr  iiiiiiiImi'  ,,f  the  liy|Mf|,vivti,.  ,a-,  -  th,' 
iiital  I,firiinati,iri  i-  |,r, ■,■,■,!,■, I  l,y  an  iinii-nal  ,lr,p|.  in  th,.  I,.iii|„.i.atiiiv,  as 
-liowii  in  Fi-    (iO.      j;,.,-,,v..n   in  tli,'>,'  ,.a,-,.-  i-  ,.\,.,.,.,lin-lv  raiv. 

(a-,-  l),.iriniiiii<r  with  liy|M.r|,yiv\ia  aii,l  riinnin^'- an  iinii-iial]\  pr,,- 
tni<-t,.c|  ,.,,ni-,.  t :,  a  fital  t<.rininati,iii  aiv  niii.-h  I,—  fiv,|ii,.nt  than  lli,,s,> 
jn-t    ,l,.-,Til„.,l.      Th(.     t,iii]M.raliiir-,.nrv,.    fiv,|ni.|it]y     i.ivsciits    iiiark,.,! 

variation-^  .jiirinir   llu'   , •-,■  of  -iich   ,.a-,-.      At    (ir-t    it    i-   ,.x,.,.,--iv,.|v 

lii.i:ii,  tlicn  it  fill-  to.  ,,r  ,.v,.n  l„.l,,u,  the  n,.final.  I  hav,.  -,.,.n  ca-.'s 
■  "■lonirin-  t,.  tlii-  nr,.,,i|,,  (Ki^r.  >;<,)  in  which  .h.-ith  wa-  ,l,.|ay,.,l  until  the 
><r,,ii,l.  ,,r,.vrn  th..  nii.l.ll,.  ,,f  th,'  tliinl.  w,.k.  and  th,.  i,.iii|„.|-atiii>.  ...in- 
tiniiiHl    ,.x,-,.-iv,.ly  low  f,,r  ,lav-  ,,r  w,.,.k-  Im  foiv  the  fatal  t,.niiiii.-iti,,ii. 

('l,,-,.|y  r,.lati.,l    to    thi-   ^-i p    i<  a  v;iri,ty  ,.liafa,-li.|i/,.,|    hv  nmi-nal 

M'M.fitv  an, I    alino-t    -taiitlv  fiial    tenniiiati.m,  in  whi,.|i   th,.  t<.ni|p,.f- 

Mtiiiv    .•,,ntiiiii<-    ,.,,ni|.afativ,.ly     low    tlif,,n^hoiit     th,.    durati, f    tli,> 

ili-ca-,.. 

Subfebrile  and  Afebrile  Cases— rni,>  afM.iil,.  ,a-, -,  -neh  as 

of.'iir  111  lyph.nd,  ap|„ar  t,i  l„.  ,.\tnin,.|v  raiv  in  typliiw  i;.\,i..  I  hav<. 
not    -,.,.!,   a   -iiiirl,.  ,|,.tinii,.    ,.a-,.  ,,f  th,.   kiii,l,  ii,,r  ,1,,  |    (i,„l    „„.iiii,,n  ,,f 

thi'iii    liy  ih,.    ni,,-t    ,.xp,.ri,.n,.,Kl   aiitli,,f-.      ()„    tl tli,.r    haml.  if   ipiitc 

' iiiioiilv    happrii--   in    the   ea-,.-    that    I    am    ii.iw  ,.on-i,l,.rini:   thai    the 

tciiip,.ratiif,.  .liiriiii:  the  ,ntiiv  p,.rio<l  ,,f  the  ,li-,.a-,.  .lo,.s  ii,,i  ,.x,.,.,.,|  .Jo° 


rnodxosis  AM)  MiinTM.iry. 


DP  cvfii  .•!!)°  {'.  'I'hi-  i-  ul)-.(rvc<l  |i;iiti(iil;iilv  in  nllv  indiv  i(|ii:il-  or  in 
V(iiiii:r  |)ir>(pii-.  uli(i-c  >ti-iin:ili  ha-  Imcii  ndiiccil  hv  |iu\(.|i\.  \\rv,  or 
cliroiiii'  (li-ia-c   licllirc  tlnii-  iiil(iii<pii   witli   I\|iIim-. 

Fii>tf:iil   (.r  a  ;.'riifi-iil    ilcMri|.lioii   uf  llii.s  variety ,  uhicli    lia.-   aevi  i    Ix-i-ii 


fully  (li'sfrilHMl.  !  will   ^rivc  tlirco  teinperaturc-charts  with  short  notos  . 
i'()rr(V|«incliii;f  case    histories. 

The  first  case  (  Fii'.  70,  wius  that  of  a  fcehlo  ohl  man,  sixty-three 
<)f  iiL'e,  who  for  months  liefore  he  was  taken  ill  had  lived  amid  the 
destitute  eiroumstanees.  His  illness  heiran  with  a  series  of  slijrht  chills, 
which  the  teni|)eratiire  v'radually  rose!  altho.  jrh  it  'lid  not  exceed  ;ii 
excqpt  on  tw-o  days— the  fourth"  aii<l  fifth  davs  of  the  disease.  Wit 
begiuuing  of  the  second  week  the  tem])erature"<rraduallv  and  steadily  1 


f  the 

years 
most 
after 
»"  ("., 
h  the 
)eL'aii 


m  ••■ 


I 

■      ,    ;,l 


./ 

tJ-    . 

H 

ii 

i- 

V  % 

P 

:>'X  Tvri/rs  //.i/.v.' 

t"  f.ill  to  Il„.  iiort.ial.  will,  a  -|„.1„  I  ,.,.  .l„,,,|v  I,,.,;,,,.  ,|,,,„|,      ^    |,,,,|,,  ^,    , 
l.'.'Mt  uus  al,>..„|   ,l„nn^    ih,.   .-ninv    ,■„„,>,■  nl    1 1„.  ,1,-,;,....      l:,,>,.-,„„, '»:,,; 


iM>  -r  II,.'  Ml-. 


tS 


■'-it 


tiit;H+: 


t  t  -t-  - 


PAl 


'T  TTT 
T  !  '  ' 


#|-T^ff|ti|r 


Fl..,  7M.-M,i|r,  „_;.]  vi,fy  l!,r,v. 


Kill  Ml  t'TiniiKili.,,,  Milli  ri  lMlivil>  Imh   I,  ^,  , 


I»'v>.,,t  i„  HiiMll   ,„„nl„.,>  .,,,1  w.-iv  v..rv  in,r,>li„ri  :   l,nl,  „„  tl„ ,,-  l,,,,,] 

nuinunn...  la'U.cliu...  mail,,  iliiir  appranniiv  la,: ,  aim.,,^' tl,,.  r„...i,la   lr..inns.' 


liH.\  cif  th..  .liMa>u. 


Fi...  TI.^Miil,  ,  ;,^.  ,1  ihiriy,    Tviniunitur..  wn=  n  liiti  v.-Iv  1„«  from  lliv  very  l..rinnii,n,n,„l  ,luri„.. 
thr  lM>t  wu,  k  frll  l.cli.w  till'  linniiai.  ° 


■»  i 


/7;o(,.Vo,v/s    ,|.\7'    Mill;  iM.liy. 


;j7I» 


.^  '■""■■ '•■''■'••  ■ri:^'"i'y  "!'  :il!-i:iinn  v,a,-   Iniiii.!  i,,  il,,-  ,niiic  In,!,!   ihr   li^ini 

"■'.^     """I    'I"''"''  •    "llli'    'l.-V.-ln|H-,l   ,M1    III.'  MM',.I|,|   ,h,v.    :l,roril|,Mni.'.|     l,v    >■.!,- 

-iiIlN-  lfii,|]iiuiu,  ,Mi|,lH)l,,irv,  and  Miullfi-iML'  (Ifliiiinn.  :ui.l  („Miiiiu.-.l'  imiil 
ilr:illl. 

I'lif   liiMiirv  i>f  tlif  .-.■(■(,iul   iii.v,  ihiil  of  :i  IiiIhm-.t,  lliirlv  vrjirs  i,f  m-c    is 
.v.n  niniv  iTMKirkal.lf  i  Fi-    71  i,      Tlic   liiu'lic-t    Icin|,..,MliM-(",  mtaiii.-.l  ",m|  v 

"" liinh-llifciiIiri'C(.iir-.iiflli.M|i,-,.a>c.  u:i>  :;:•.!     (  ■,.  and  IV.irn  llii- .-cvcnlii 

II.  III,.  tiMii-trciilli  day.  uhcu  dralh  nc.nirr.'d,  lli.'  tfnij.ci-alni-.-  cnnlinurd  i,, 
liill  tn  S.I  niai-krd  a  (IcLrr.c  thai  dnrin-  tlir  la.~l  H.nr  da^-  it  rant;.--!  l,,.|u..fu 
■■'•r  and  ;;.■,  ',  and  cvmlnaliy  dro|,iHd  lu  ;;:;.;;'  and  .iL'.l'  (''.  jnnn.diaulv  iK-lor,- 
'Icat...  In  -p'lr  iifthi-  iinnsnally  Inw  tcni|.<TalMrc  ilic  |,ali(i,t  .(iiilmncd  in 
VMilfiii    drii       m,  and  was  cniii-cly  iincdnscK.n.-  until   tui.  dav>   li.-lia-,.  dcatli. 

'''■,"■'•"*  ' «■='!<  l'>  ri^f.  iiiid   lay  in    licl    in  a  siaic  of  ciMisiant    rest Icssn^N^i 

'■i-yini:  an. I  ycllinL',  at  la.-l  .jnictini:  'i'-uji  an.!  tallin-  into  .listinct  cunia- 
vi-.l   .Innn-tlic   last  twi-ly-fi-lit    Imni-s   pivivdin- .Katii.      For  tiuvf  n.oiitlid 

l>iiy  ..f  Ih./  .li-ciisc. 


Fl.i.  7'2.-MnK-.  a^'  .1  tliirlv  live.     FiituI  .ii.^u  w 


ith  v.ry  l.iw  iiiii|>.rMtiin'.     K.l.ris  fTantliomaticus 
rfiinlis. 


l(»'ti>r 
eaten 


T,  his  adrniltan.v  the  pati.'.it  had  horn  with,.iit  a  home,  had  srarccly 
Ml  anytliin-  and  had  .Irnnk  lar-,.  (|nantilics  of  whisky. 
(•oinheMiaiu  reports  l'  very  similar  c.as.-s  witli  a  marked' tiill  of  tcniiHT- 
atnrc  m  the  hist  days,  ni  one  .-asf  to  :;;!.7°,  in  the  ,,th.T  io  .•';l  '"^  ('  Tids 
eontrd.uti.m  is  the  oidy  one  on  this  sul.jeet  found  in  re.ent  literatnre  a.u'i 
even  ti.e  oldest  authors,  sneh  as  HiMeTd)raii<l.  refer  to  the  eondition  in' very 
indefinite  terms. 

-V  thir.1  ease  .nat  I  shonl.l  like  to  ad.l  was  that  of  a  man,  thirtv-five 
years  ot  a-e.  who  died  .m  the  ninth  dav  of  the  .lisease  rPi.-  7-')  "  The 
temiR.ratnre  ,n  this  ,,,s,.  ran  a  ivmarkal.lv  retrular  ami  .•onstant  eourse  at 
a  eompaiatively  low  |,.vel-hetween  :\s-  and  :i-)°  ("—and  nothin-  Init  the 
exee,s,s,ve  weakness  and  fre,|nen..y  of  ,he  pulse,  whieh  were  pre.s,,nt  fron,  the 
IxymmnL'.  sn-resm.l  ,,  f;„al  terminati..n.  .\t  the  time  of  his  admission  the 
patient  ha.l  a  well-niarke.l.  eloselv  a--re-Mte(l  roseolmis  eruption,  whieh  on 
tlie  htth  ,hiy  of  the  di.sea.se  rapidly  underwent   almost  eomplete   hemorrha.ac 


580 


TYi-iifs  mil: 


Iniii-liirniatiiin.      In    ail.lilinn    h. 


till-    lir    !.n>,hi,,l  UN  !h,-  .|:!\   ,,(■  !,,..  a,li,,i.- 


M..M   n„-  t,„u-,i,  ,i;,v  „r  ,1,..  ,1,-,....  .;,„,„ „,  „\.,;.;.  i,,,„„,,|,w 

2':7]tiur t1  ""'■"; v """■'"!—■ ..i,..::;:r 

-l.r      ,t     l„>    ,ll„.>.-         Il.,>    :,n,l  .-m„l:,r   ra-.-.    ul,„l,.    , ,„    |„,    ,,„„„„,,| 

'■"••"'■'•-I '"I"  I  III,-    l"nu-    ..,,■, HI  in.'    11,    l\|,|„,i,|    iVv,,,-. 

'■'^""'  '""■-"'■ -'"'■••■■'■' '"■^"•1^  -li"i'  'liir:ili..n,  „|n,|,;„v,|,.-,TilH,| 

'"■    ''""I'l"''   ^'ii'l'"i-    iiii'It    lli.t.nn    typhus   SideratlS,  v.m-n    in  Ir,- 

<|ii'ii(\  III  ill,.  iiiii;.|,.|it  i|.hl(iiii,-.. 

■IIhn    :i|,|„.,,-    ,,,    .„.,,„•    .,|„,i.ilk    al    tl„.    lM..,i,mi„,r   .,,,,1    ,|„,i„.    ,|„, 
li'iiilil  -I    o,|„, •„!>,.    „|.,n.|,aiit    .■pi.l.'Mii,-.  lurticiilarK    -.ihli  a-  ,„.,.|ir -m 

;'':|''"'^"'''    '"    I"' -■   '''"i"^    ^1    -i-^".    "I-    in    I.-IK"   .„ana,..,|    aim,,. 

";''''•"'"•""'■   M'liilii- <irav..-,  aii,|    mli,,-,   a>n,.ii::  tl„     ,.|.l,r  ;ni.l„,iv 

<-n.i"V,..l  an  aluiiMlant    ,N,„a  1,-n.v    rr,„ii  „|,|,.|,  ,,,  ,|,,„,,1„.    ,|„,„.  vaii,li,.. 
It  Nva.  ,|iii„.  ,,r,.val,.|it  .Inii,,^.  Na,,..!,.,  ,„',  ,,„„,,,,|.„,  ,,„|  i,,,  |,..  ,  vina.an 

"•"■•  '■^l""'^'">^" ^    ''"■    '■"'•■•'I'll   ami    l.'u.-ian.,  «|„,u,,,.    ,i,,I    luarlv 

.M.wll    l,„,k.H|  aCt.T    in    lli.nialtrr  ,,(•  l„,il,|,    ai„l  piaml    .„,i,li,l,,M.   •,'. 
Wen    til,'    KnL:li-li. 

'I'lii'  ^-r,,!!,,  ii„|,„l,..  ,,,„.,  ,.n,|i,ij,r  ,:|,.,|K.  ,,j|i,j„  .,  ,;.„  ,|,^^^  .^,.^_,  ^^^^_ 
api-'aranr..  „f  ,|i,.  li,.,  .vM,|,tu,ii,_„,,>alK  l.,,u,.,,,  ,|„.  Hiinl  mh.I  tifih 
.lav.,  ,„•  rvn  .arli.r.  .M,,-t  ,,f  tlu  in  l„.:,ii,  „i,|,  a  vi,,l,,,(  ,.||i|l  a,„|  a 
".•ll-.l.v,.|„|„..|  -|,1,.|,1,.  ,.|ilarp.,M..nf.  Tli,-  l,.M,|„.rat„r,.  ocnrrallv  ihkI,.,- 
PM..  a  rapal  and  n.iint..m...t,„i  ,;.,,  ,,„,in^r  „|,i,.|,  ,|i,.  ,,„i,,,t<  ."..niplain 
.iMh..  ni,M  M,.!,„t  .unptun,.:  nnuMiallv  m.v.tv  lu.a.la,li,.  an,!  pain  in 
tlu'  i.a,k  aial  ln„l,~.  a,,„ni,,a.ii..|  not  mivk  l.v  nn,nntr,,llal,l,.  v.,n,itin,r 
^i-i'l  ivl.-Inn/.  Tlu.  Irni,M.ratinv  n-Mall.v  r,.a,.|i,.<  a  u^ival.  an,|  ..nntin,,". 
an  ..x,...-Mv,,  ,„.i.ht.  A...arlva>  ,1,..  IIpm  ,|;,v,|,„  pnU  j,  „nnM,a!lv 
>rnall,  tiv,,,,,,,.,  ami  niav  l„.,.,,ni,.  inv-nlar  in  v.^lnnir  a;al  rlivllim 
...1  tli<.  >,.c,,n.l  -lay.  'J-|ie  pali.ni..  uli,,.,.  n„,ilal  .-oiMJiti,,,,  !„.," 
••lnM.|ca,,n  til..  ,.v,.ninjrc,ftlH.  lir-t  ,lay.  ciiji,.,.  ,|,.v,.|,,|,  vi,,i,.nt  ,1, 
la-tinLT  until  di-atli  cr  -ink  int,i  cuna-viuil. 

Drath  i-    pr, .,.,., I,., I    |,_v  MMipl,mi-.    ,,f  , Mnni,.    .aniia,-  u.akii,..-.  and 

i.M.ally  l,v  an    ..x,.,...iv,.  Irniprraliiiv—i, ,,,-v  I  suv  a  hyp,  rpvnxia 

..I  (L'.<;  ('.  Tl,,.  .pciticniption  i>  n,,t  ran  |y  al>-,  in  ,„■  imt  -paiiimlv 
'''■'■' '"l"''l:  '"  II-''  ■■m  cxpiv-i,,,,  ,,f  111,.  ,,|,|,',.  pliv-i.ian-,  i,  ••  Mi,"u 
•iii'l' rnra.li  tli,.  .kin."  .\r,.,,rdindy.  tlir  dia^nu-i-.  V.p^.iaJI,  „-l„,„  ,|„, 
<lni-atin„  i-  v,Tv  -li,,rt.  i-  partimlarly  dilli,.nlt.  an, I  ,l,iiinj:'  lar-,.  ,pi- 
drnii..^   can    !„•    nia.l,'   .mlv   Iiv  ,.xrluH,m    and    liv  ih,.   .|,.t,.nninati,,ii    ,if 

]..ni:-(.,,ntinnr,|.   ,1,,. ,uwi    with    «,  ll-,nark,.d    l^pl,l|.    f;.v,T  ,.a>,-. 

In  till,  wav  ,,n<.  ,.aii  iiii,|,r.Iaiid  i.,.rtaiM  ra.,..  ,|,..,Til„.,l  l,\  r,  li^Mc 
aiitli,,r.  a.  la.tiiii:  "iily  nur  nr  t\v,.  days  .,r  a  f.w  li,iiir..  I',.r^,,nalh  .  1 
Iwvc  ncvvi-  iiu.t  witli  i-.isvs  of  Midi  short  diinition.      Tl,,.  ,Hii,.k...t    fatal 


(■i.ni,.s 
ii'inni 


ri:>)ii\n\l\  .i.\/(    I/O/./  \i  1 1  y. 


581 


<-;i-..'  I  li.v.-  l,.„i  ,„,,,-i..„  „,  ,,i,-,n,.  i.niiiinir.l  mi  iI„'  ni-ht  Imiu.,,,  i|„. 

\\\\r>\   .'iikI   t^Pl'llli   iliix  >  m|'    iIic  i|i-ra-f. 

I  MiiiM  iioi  ,,Miit  tn  iii.iilio,,  dial  M  tii,ii..rily  u|'  ili,-.  .•a>r- miv  .lur- 
a.lrii/,-,1  l,s  mark,., I  all.iiiMMiuria  fn.in  il,,  ^,^■^  l„.;:i„,iirii..,  an,!  i|,al 
'li|'litl.'ri.'  aiii^iiia-  air  ili-liii.t  l_v  mimiv  ln.|ii.  i,i  tlia.i  in  lli,.  ..il,,.,-  |;,n,i- 
111'  l\  [iliii-    li\  (  r. 

Ami,...-   |I„.  i;„„,-  ilial   al.„.,-l  alua.N-   ,.,,1    lalalK    ...i.-l    I,..    iii,|,„l,.,l 

the  s,)-,  il|,i|  hemorrhagic  cases. 

•^''' -'i  'I''-  \:ii'i.l,v  always  iv.viv ,- raivrMl  ,-,,|iH,|,.-ali,,M   in  ,|,^,|i|,- 

lioii-  (it  III,,  a, ■I.I,.  i.\aiillii.Miala.  I.i.t  liltl,.  atlciifi.ni  i,  .|,.s,.t,.,|  .,,  |t  ,.\,  „ 
III  <ar,ri.l  il(-rri|,ti,,ii<  ,,|-,.|,i,|,.||ii,.,  ai.il  in  iii,iiioL'i-a|ili^  ,,ri  lyiim-  f..^,.,.. 
KmiiiIv  a^  ill  ill,.  i,.,.i,.  ..\a.illi,.|i.ala,  llir-..  ra-o  |.iv«,.|ii  a  -ivat  \aii,.ty 
nf  i.ia.iir,-lati,ii.~,  ami,  fur  ,.\i,  inal  na-ni-,  liny  may  I,,-  U  -t  .li\  1,1,^1 
into  tlir  f.ilii.inaliii;:  foiiii  and  tli,.  tnnii  liaviii-  a  >.,ii„.ulial  l,,iii;,.r 
<li.rali,i.i. 

.\lllini.j:li  ,.a-,.-  ,,(■  III,,  fiijiiiiiiali.iir  |„.„i,,r,-|ia-l,.  Inriii  .,fty|.lHi^  f,  .r 
arc  .■xr,...,linu|y  raiv  in  c.m|,ari-,,„  wii|,  ij,,,,,,  ..f  M.iali-|...x  oC  fh,.  to.-iii 
<l.-.Lniat...|  as  j.Nr/,iin,  n,rinl,,.s,i,  th,.  two  (iiiiditiuiis  iifv.'itlicl.s.s  |i,,-css 
many  |Kiiiit-  in  ciniii.nii. 

'I'll.'  t.iii|,..ratiiiv  Hh.s  rapi.lly  t.i  a  -rcat  liciVlit,  a.i.l  ,.llu.r  >..v,.r,. 
;"''''i'  I'li'Mnii.ri,aa.v„l,M.,-v,.,|.  With  tl.Hiivt  a|.|M.an.i„.,.  ,,r  t|„.  rasl,_ 
II.  the  ~,.v,.r.-t  ra-i-  at  tlir  .1.,!  ,,f  til..   H.,,Mi,l  ur  lM.Hi„„i„jr  ..f  tlu^   thin! 

''^'>  "'■' lix'i'-.',  ImIhiv  li..n.  is  any  M^r„  „(• ;,  la-i.—riiMii.T,,...  ,„.t,.,.|,ia. 

mak,-  tli.ir  ai.|iraiaiM,.  and  aiv  iininr.  t,.|y  (;,||.,w,.d  l,y  ...xfiiMvc  livni- 
"iiliaui.s  int.,  ,|„.  ,ki„  :i,„l  snli,.ntan....ns  ,.,.|l,.lar  tisM,,.  ",,»•  th,.  trunk  and 
.•Mivii.jti,-.  Th..  ninjiiiHiiva.  aiv  inj,.,.t,.,|,  ai.,|  h..|ii,,rrhair.-  (n.n,  tlir 
lil>s,  t.m-i.r.  ;:i„n.,  and  ii,.-,.  n.akr  tli<.ir  a|.|M.araii..,..  Tin-  i.  i;,||,,u,.,l 
l.y  ..,.,.hy,„„M,  and  ..funin;,-  „f  th..  |,hary.,jr..al  .tn.,.t..r,.s  aii.i  .li|,htl„.ri.. 
.•.M.d:,t„.,i  ,.r  -i,..,.,.,„.  „r  ,h,.  n,n,.,M.  ,n,.,nl,raii...  S,„n  h..n,atiiria  „f 
.vnal  .iri^Mii,  wiih   M,n,.  „f  -,.v..,v   n..pl,r^i-,  aii.l   aK„  li,.,„al„ria  ,!.„.   t,. 

' ■'''■'-•■    "■'""  •!"■   P'lvi-  -f  the  ki. y  and   the   l,ia.l.|,.r,  aiv   mi,„.,- 

a.l.lrd.     M^my,,rtli,.,,a,|,.|U,,.a,.|y,.x,„,.,.„,,t,.aM.n.sanir,.i,„.„nss|,..t,.,n. 
""■'■.•  aiv  ,.,„i.„li,la,i.,ii-„f  ih..    ,i,iln„.narv  ti~Mi..s,  s„„„.ti,„„.   .,,„1|,„„    i„ 

jxan^rr,.,,,.   „(    tlio    I, ......       Int..-ti.ial    h..|i„.rrl.;i^r,.,    and.    in    ,1 as,.    ,,r 

w..iii..n,  al.iin.lant  nwiroiTliauia  ,.,,n.|,|,.t,.  th,.  li,,nil,l,.  ,.|ini,.al  ,,i,.„„.,.    ,„ 

"''"•''    ''"■   "'''"'•    ^"'"""-     "■'■'•<•    i"    til"    h.ihit    „r   applvi,,.-    the    t..r,„ 
"  r  ai.lti,.|i,.r." 

In  ii.,,-t  ea-..-.  tl...  a|.|M.a.';in,.,.  .n.d  ,i..v,.|,.i)M„.nt  ..f  th,  h..|n,.iTha-e* 
iiv  a,.,.,.„,,,a,ii,.,l  l,y  a  nipid  fall  ,,f  th.-  i,.in|.,.ran,.v,  uhi.-h  off,.,,  sinks 
t"  an  ..niiMiallv  !,,w  l,.v,.|  j...t  JM.II.r,.  ,!„.  ,.,,,1.  V„y  ,lavs  |„.|;„.,.  ,|,,,„|, 
It  IS  .iften  im,„,ssi|,i,.  t,,  t;.,.l  the  |ii,l.,..      'IM  this   ,.xtr,.|.u.  pr.istrati.ii.   of 


:,H-2 


ryriirs  iivi  i: 

Im      :lt|  I  llillli 


iImi-h  -u    Ih.IJI-,  ' 

Mi\    I, null  ,|.  tlir\  •  ' 


"  .^    ■iiv    liriiil\    iiupiv— ,,|  , 


ri'A.i-    ."■.iiiiv. 


"     '".^      ""  lllnlv.  II,   |,|.|l,l,„.-i 


'"'■"'  :^'i''"'"'"  ""-I 'I- ..,..    .\,i„i,i.  „n,..  ^.a,.  „r 

;'"■•  ",'":'  l;'-';—  ^'  -M-^l  ■-!.  uln,.|.  la,., -I,,.,.:,,,,,.  ,;.„i,.,iiv 

';;;"""'■'"• '•'^^'•"' 'i"--,:,..!,.  ,i •,..„rui,„.i,  „..  ,i,„;„i 

:;:;'''■''-■''■'"'•'''•' ^' '-'--' --i -u...: .,„.... 

C-.l|l|ll.ir\       ..../ll]^;. 

,      ''''"■'"":'     ■";'''""    '■--    '"    'I'i-    ^-■-1.-1 ,l.„    ,.,,,1    la.allv 

':;/;7''^';'''''r''' '■'''■''' '■  ^-"— i ■.1...,..,,,, 

""''^'-"'  '"  ''"■  ^'i-.v  l'--i„im,:..  ,,|-  ,|„,  i„i,i.,|  ,,,,„. 
,     ''.""■;"'• '    7-^'l-"l„.   I„. .,,,.,71.. -.ul,i,.|,,M,-i,.,lv 

'""'"■'"•  '•--'i""'i„.,„.,„ i-. i,a,i,ai,i„„„i, ,.,;,,„„_„;:  „. 

uyu.U;a     ,.,.,..,.|„a..    a.    w.ll    a-    ,l„.    |„.,.vi„„-lv    „„.,„:,„„.,,    „,„,„,, 
"•iitaiicniis    lici„,,ri-lia!.^,-.. 

Tlh-    iMIipcl-allllV-rui-s,.     i„    thr.c    ca-,-    i-    v,ii,l,l,.-      ,  ,„ 
I  -11,  .1.1      \aiiari,i',    ^(.tiir   ca^cs  arc 

Hiarari.,-,/,.,1     l,v     liv,„.,-,,v,vxia  ;     ,„|,„.,    ,,,|,i|,j, 
•■"iii--c.    uitli    r,iarkc,l    iv,,,i^M,, 


'•'I'"':   •'-•""•   'l"'i-''   ■•,,•.■   .■.•IV-    i„    Mii,.|,    ,|„. 


1,1     ,i-,vi;iilar    (M, ,.;!,. 

',,-    "I-    'Aril     ii,Ir,.riii.--i,,,i-    si|ujr,..tj,,jr    ,.,,]. 
,.,,,  .    ,  .'|".ir:,ii.v   ,,r  til..    Iiriiicr- 

-":    '~    " '"""■''    ''^-    ■■'    "-'■!-''    I^'ll    in    ,l„.    ,..|ii,„.,.a,i„...,    „.|ii..|, 

'''-■'---  •''^'V''"  '■''^''^''■''■'''"■''  ''•''-''  'I- -■•••v,.,,,..,|.v  ,.,•.,,, .,,,1 

'"^"'    """'"'"'^ ni.-iTlia,-,..:    on,.,.    i„,„    „,.,    |„.,i„„„,,,,„„.,.    ,„    „,,, 

'  r,-/,,,,,,,,,.  ./,,„,,     ,,„,,     1^^^ 

'  •'^•'■<lil-.|,1„,,, ,.,...  Dip    |.,„,|„,  ;,;,. 

,        A      ,»>.,„    -    Uuiiill,.,    >.•,.,, „.l   i-cl,||,,,|,     vol.    i. 


/7.'/(,    \//S/,N        I    \/,       I/,,/. 


/  I/,// ) 


5H.-1 


-■l".ll-Mu,l.,l:,||„„„mu.i:,    i-   a   ,„„-,. ;•.„„•..., I-  ,|„-^:,n,.^      „mI 

^''"';:'".",""""'''^'^'-" ■'>,•„,:„.,,.-.,.,.,,„.. „„,„,„.,.,„.;,;„.... 

'"■  "^'"'""^^  -i.,.ai„.w „ „,,,„„,  ^,  ,,;,,^_,,^  ^^_,^^^^^_ 

'","'^    ''''"•""'■•    ^'1'' -''    •!'••    '"^'J""i>     ,„•.-..,„    ,1,,    ,.,.,,,1,,..,    .,^„_^,,_ 

.i.lMiaiMi.-   '    |i,rm    ,,|'  il„.    ,|i-,.a-r. 


.|H.<- 


PROGNOSUi:    MORTALITY. 
General  Consideration  of  the  Mortality-rate.—  II,,. 

ti.M.  a,  ,„  ,l„.  ,Mu,-.:,|i,_v  „!•  ,v|,Ih,-  l;^,.^  i„  i,,  |„-„a.|,.-,    -.,,-,.  j,  „o.  ,..,-v 

'"  '■"'^'"''-      ■'"' '''■•■•    ^t^"i^'i'--  ^'1' '^1.    .•xhMMvv,   a,v  „(•  „„  val,,;. 

'"'•H,..  ,v|,l,„„l   an.l  ivIai.M,,;,^  ti-v,,-  uvr..  not  .li-,in^,.i-l,n|  tr,„„  .vpl,,.^ 

I'""''""''    """'•'""    '■^-■" -^""I    '1-    'i;:M,v,   .i....    an.   ,l,...v.;;,v  „H> 

Kvrn  in  lat..,-  lin,,-,  l,„„..v,.r.  u  I,,.,,   ,|,i.   .Ii-,in,.(i..n  ua.   mun.  a.vn- 

■■^'"^-  -MM,l,.,,lMT..,,a,M-i,.sa,v  t„„n,|  ,l,a,  ..ann,,,  l„.  attnl.,,.,.!  alt .tl,,.,- 

"';'7'" i"  "'-li—.  1   ..  ,|,.,,..M.|  nal,..,-  -T,„.,   .,,•.. |„.,;„i„„ 

iiiid  dia^iin-i^. 

Tip.  ,rr,„.  ,M,ally  ...Mil,  in  an  ,.v,.,.-mv,.|v  lu^l,  ..Min.at.  oC  ,|,.. 
■"■"•'al.ty.  ,.,,„„.,allv  ulu.n.  a,  ua~  ,|„.  .a,.,  n,  ....-tain  .v^^ion.  a.ul  ..t 
'';■;■"'"    '"■■':"■'-  """'''■^''    ""-  "'•'■'■   "-'    -M.li,.i,.n,iv  train,..!   „.  ,...,..„nn/.. 

A.,.,|-.|,.v.., ,,„.,!  l„nn.an,|    .la.n.t;,,-,.    I,a....l    ,|„.i,   .,„i„i,„    .,„.|,„i;,,^. 

""    -I-    uvll-,|..v..|„,,..,|    an,!    >..v,.r,.    ,.a...    ,ha,    .ann.    un,!..,-  tl,.!,- .,l...p. 
vat 

A^ain.  al,|,„n^l,    tl,.   a.t.n.pt    n,id,t    I,,   ma,!.  „.  ,.„n-..ot  . .,•,•„,-  in..i- 

:  7    '""";"^"'; ''-'■''•"'  :.llnnn,h,.,.„r..a...|,v  a,-i.,n  wit h 

.Ha..,,  nu.nl.,.,.  „,    .■..,.„■,.  ,|..,.iv..,!  n„n,  vari„n.  ,.|,i,|.,n,i,.s    '....nn-in..  -.t 
van,,n~,nn,..„.„.l,..n.nu.,nl.,.,...,ltl.a,tl„.n,ali., v  „r  tl„.  Wi^.'o 

.-nl.,.,.t    t,.    tl,,.   „...a,..-t  variation-.  n,„    .,nlv  in  ,iifK.,v„t    I.,..aliti,..  an,l 
at    van,,,,.    ,.,.,.„„1„    |,n,    ...,,.    ,ln,-in,.    ,li,r,.,...nt    ,,..,-!,„!.    „f    ,|J 


■an,,' 


<'|)i<!(.|iii,.. 

■M^i..,alltl„.|,„i,.nl,i,.-n,t„a. U  a-  ...II    a.    ,„..i,,,.,,  tl.,.    n„„- 

'■'■'■    "'V'r    ''■^•'■•-    '"    ---'    -V  I...    ,,Ia....,!   at  n ,   15  t.,  •.,,,..,. 

-'.      ';•'    l-.'l-vf;„-...  that   tv,.ln,.|;.v,.   is  „„...,•  th... no;.!,.. 


if  I 


TV  I'll  IS  I  F.vr.i:. 

MinTl.-'«.ii.  wIkw  stiitislics  oi,  111..  -..ii.Tiil  iu.>rlMlity  ;uv  wuA  chilH.rate 
una  l.;isr,l  om  iIm-  Imp.'cM  miumW.t  cf  <"isrs.  u„  ll„-  1.:,m>  oI  4 ,  > ,  .■;,>,>  nvMl..l 
i„  th..  l.on,lnn  i-.'V.T  lln^|,ilMl  l,.-t«r»M,  IMSaiul  iHi'.'  ,-,lrMlMtr,l  ,1h-  ,nnr- 
t'llilv  U  -'OM'  IMT  .ri.t.  Anion-  !l4s.".  r:i>cs  inlniitlnl  I.,  llic  Intirmary  at 
(■la^M.u  iliiiin-  a  |.cn."l  of  ..U'Vcn  Vfars,  la-  i-q»"-t.^  a  inortalitv  ot  l,s  |,..r 
tvnl  aial  -1111011-  I:i7t»  iiatii-nts  ir.alnl  in  aimtlur  (.la,-'_'ow  lio>piIal  llio 
,u,„-.alitv  ua.  i:;.;,  or  IT.'-':'.  |i.t  r.iit.  Alnr  .•oU.T.iu.^  lliv  .■nornions  nmnluT 
of  is,.-)'.!!'  raM',-.  olMi-vf.l  l.y  liiiiiM-lf  ami  oiIkt  antlioiv,  Mni-cln>oii  tiiiall) 
.Ictoniiiiif'l  ill.'  nioiialilv  lo  lir  l^.TS  jicr 'vnt. 

K,.,,,,,  iMV  anaUM^  of  ilu-  liTf,  ra^r.^  tlial  I  obMi-v..!  111  Moalal  m  llir  vrar.* 
from  ls7(i  U<  \X'i'K  aliuoM  all  of  Nvhi.'li  ranio  from  tlio  moM  ilotitiilc  .'la.-M'S 
of  ihr  |,oi,nlation.  1  oUlaincl  tli..  alarminir  litrnro.if  :^:;.4  per  .rnl.  1  l.f 
ili-trilanion  of  llu'  casts  for  tlu'  tlir.'o  years  was  a-  follow.- :    _        _ 

\(lMiitliMl  in  l^Ti;,  14S;  iloailis,  4ii— '-'7  por  (rnt.  :  m  1>,N  .^i  ;  'Katlis. 
o._)__-j,-, :;  |„,,.  ,.,,,,1.  ;  in  1.^7'.t.  441  :  .Icatlis.  ••7— iM.x  prr  r,hi. 

A  niorialiiy  of  tVotn  lo  t,.  1 'J  per  .vnt.  or  ovrn  lu  p,  r  mit.  aial  l.-s 
|,a-   li.rn    ivporiod  in  a  fou  .■pi.l.mir-  of  minor  .vt.nt,  ,liara.'t.Ti/c.l  l.y 
uniiMiallv  favoraMo  .•on.liiion.-.     It  far  moro  fro,|nontly  liappcn>  tliat  .lu> 
„„,rtalilv  ri-.-  al.ovo  -J.i  an.l  a>  hi-h  a-  :!n  l-or  r,  nt.      S.irl,  hi-ii  ti-nns 
,„,,  ,,,„.h,,,l  i„  ,.pi,!,  nii<-  «  ii.n  the  HMJal,  an.l  .■onH..pi.nlly  tin-  in.liv  i.lnal, 
,,„„il,i,,n-aiv  paiti.-nlaily  nnti.vorahl.— a-,  for  in-tan.'c.  wIkmi  tli.' <ii--aM' 
l„,ak-ont  ill  liinr-  .,f  ^var  ..r  famin.'.  .m  -hiplioanl.  in  pri-.ms,  an.l  nn.l.T 
,,tli,T.-p.viallv  nnhy-i.'iii.'  .•ir.nm -tan..-.      I'n.l.r   -n.-li   .■..n.liti.m-   tlu' 
n.ovtalitv  lia-  ri-.Mi  a-  liioli  a-  .-.n  i-T.-.-nt.     A-ain,  1  may  .at.- th.' (  rim.an 
war  an.l    Nap.il.-n's   .•ami.ai-ns.      In   v.ry   r.'.vnt    tim.-   r.|...rt-   ..f  an 
,„HiMialiv  -v.'iv  f..nn  ..f  tlic  disca-..   Iiav.-  li.'.ai    r.'.viv.-.l   fr.an   various 
n...Ion-.  '   Tlui-,  I>ar.ii-na.''  .■al.'ulat.-.l   tli.'  mortality  at   :!i;.;i   per  -•out. 
'  In  lio-iiital-  a  ni..rtalitv  of  fr.mi  -I'l  t..  'Jo  p.T  .cnt.  i>  .piito  .•omin.m. 
It  i-.ifton    Tivat.T   than  it   is  amon-  tlu-  .ait-i.l..  p.ipnlalion    .l.irin-   the 
s.,n,o  ..pi.l.ni.i,-,  .il.vi.Mi^lv  ..svinjr'.itl,.-  fa.-t  that  a  ivlativ.4y  lai-.'  nnmh.T 
of  .■v.-iv   ...M-  arr   a.linitt.Ml.      TIh'   hiudi   mortality  of  -1.14  p.r  .•out. 
that  w  ,1.1  ill  1S7I>  in  Moal.it  .■onl.l  U-  hronjrht  .lown  t.i  IS.S  p,r  .-.■lit. 
i    th..  .-as.-  a.lmitt.Hl  in  a  m.ailHin.l    oii.liti.-n  an.l  tli..-.'  that  di.'.l  h.loro 
,,,„  ,.ml  „f  iortv-,.iuht  h..i.rs  w.mv  ,i,'.!n.-t..l  from   tii,.  total.      .Muivhison 
mUo  -tatos  that  tho   m..rtality-rat..  in  iii-    tTS7  .'aM-  wonl.l   I-   iv.hi.rd 

were  t.i   make  the   -am.'   ic.-iiva- 


tr.  >m 
tio'i. 


2(1. Sit   to  17.0    piT  i'<'iit.    it    la- 


Tlw  .•..n.litio,,-  that  .l.'t.rniin.'  tli.'  .•hanicfr.  an<l  ..-p.'.aally  tho 
mali.niancv.  of  tli,'  .lis.-a-."  an-  a-  luim.'naw  a-  th.v   aiv  variaM.' 

Th..  poViiliariti.-  of  tho  lif.-lii<t.iry  of  th.'  -p.nti.-  or-am-m  an.l  tlu- 
,v,.'ti..n  .if  th.'  lio.lv  t..  this  .irjrini^m  an-  im.pi.-ti.nial.lv  m,i-t  imp..r- 
tant  f,.'to,-..a,..l  w..'. •ann.it  li.ip.'  .-.iHy  t..  nn.l.a-tan.l  th.-.-  until  a  in.nv 
thoniiiLdi   Unoxvl.'<lcr.'  of  tli.'   mi.ro-or-nni-m   i^  ohtaiiuHl. 

1  D'-part.  (hsf,  lf<'.i3. 


iiffiattt 


4. 1 


7k.  !  . 


i>i!()(:.\()sis  AM)  MoirrM.rry.  685 

(;»nrr;il  external  and  personal  conditions  liavinj:  an  inlliuucc 
ai'c.  rcl,..i\(l\   ^]H•akin;.^  iini<-li  licttcr  kiinwii. 

Aiii.iiij:  tlic  -nicral  cxicnia!  cinitliiidn-  geographic  distribution, 
weather,  and  time  of  year  were,  im  dmil)!,  foriucily  of  iiuicli  urcati  r 
im])ori.iMC('  tliaii  tlicv  arc  to-day.  Certain  ol'  tlic  nldir  autlioiv  >tatc 
that  tlirv  (il)~cnrd  a  ili^timt  iiicii>a~r  in  tlic  virnlrn<-c  ..!'  typhus  t'.'vcr 
in  ci'i-iain  coinitric^  and  (hii-in^r  "■crtain  -ca^on-  and  wciithi  r  ronditions, 
l)iit  at  |irc-cnt  we  know  tliat  sm  li  factor-  arc  only  indiivi  ily  iniiiortant  in 
so  far  a-  thcv  aH'ci-t  the  -ocial  and  jicr-oiial  coiidilionxif  the  |Mi|iulati(.n>. 

Ilcfcrcnci'  lia-  frcijncntly  l>con  niailc  to  the  fact  tliat  LTcat  national 
di-titution,  famine,  war.  and  -ici^cs  fav<ir  t.hi' dcvclo|)nu  t  and  materially 
incrca-e  ihe  malignancy  of  the  di-e:i>c. 

Anionu-  individual  conilition>  age  nmlonhtedlv  exerts  the  "greatest 
intlncncc  on   the   mortality. 

In  childivn  and  yountr  individnal-  nnder  the  ai^c  of  twenty,  Jn,-t  as 
in  tv|ihoiil  fever,  the  mortality  i>  low — not  more  than  from  'l  to  ■">  per 
rent.  it  i-  materiallv  lii;:hcr  hetwcen  the  a^^c-  of  twenty  and  thirty, 
and  in  severe  ejiidcmies  niavlic  donhled  or  more  than  douhlcd.  lictwceii 
the  ajrc-  of  thirtv  and  tiirty  the  mortality  is  fonr  timc<  as  liijrh  as  amon^ 
individnals  of  nnder  twiiity,  and  after  i'orty  it  n>c>  to  a  stn|icnd<>ns 
lieitrlit.  Thn-,  in  Moaliit  in  1S7H  almo-t  two-thirds  of  all  the  deaths 
tK'ciirrcd  in  individual-  over  forty  year<  of  aj,'e,  althonirh  of  the  entire 
nnmlier  of  patient-  admitted  only  one-(|narter  were  of  this  a^'-c  .Vjiprox- 
imatelv  the  >anie  proportion  has  l)ccn  ol)-erve<l  in  other  epidemics. 

Tlicre  is  an  interestiiii:  ditlerence  in  the  niortidily  in  the  three  periods 
of  childhood.  This  diHtTcnce  is  sharply  detiiied  and  has  l)een  ohserved 
with  iTcat  reirnlaritv,  Init  no  >atisfactory  ex|ihniation  has  so  far  heen  offered. 
Children  inider  five  years  of  aire  are  in  jrrcatest  lianircr  from  the  disease, 
whereas  the  period  hetween  ten  and  litteen  years  exhihits  the  most  favoral  le 
niorlalitv.  In  the  latter  jM'tiod  the  mortality  raiiL'es  hetween  ().•')  uiiil  4 
per  cent.,  whereas  ainonir  children  under  live  it  varies  from  ti  to  12  Jier  cent. 
The  intern'ediate  class,  'omprisintr  cliildren  iietween  theaL'esof  five  and  ten. 
occupies  a  eorres|)oiidin;r  internieiliate  position  as  retranls  tlu'  mortality  i  4  to  i 
percent.).  In  illustration  of  this  jioinl  statistical  tahles  of  Murchison  and 
<  Jnitzer  are  added.  The  former  collect(>d  his  stati.sticw  from  the  records  of 
.')(i:>  children  in  the  London  I''ever  Hosjiital  : 

I'lulcr         "i  yriirs 

Bctwi'i'ii     •■>  Mini  in   Vr.'ir-  .     . 

10    ■■      1.-,  '     ••        .         . 

(Jr.il/.er  ha.sed   his  cali'ulations  on  \')>^  ca.'^cs  of  ciiildren  in  the    Hreslau 
epi<leinic  of  1H()!I : 


A.lliiilUil, 

Iti.'d. 

Vvx  < 
1  ~ 

.•lit 

IKi 

14 

7, 

;.-, 

;>,;;! 

IS 

I 

i."i 

I'li'lii'         'i  yoiviv 
liilwirll     .'i  mill   10   \riir- 
"         jo    ••     l.'>  ■ 


Ailuiiltcil. 

nicii. 

IVr  .-I  lit 

l.'i 

1 

li.tii'i 

41! 

•  ) 

t.Tc. 

101 

1 

o.'.i;i 

-j.Sd 


TV  nil's  I IV  i:  11. 


n 


•'^?^ 


'I'd  illu-li-Mti'    llic    iiiorlalily  :uii'iir_'    ;ill    :il;i->    1    -ivf  iwo  l:iMi>    l;i>iilnM 
vrrv  hirirc    I'lLMiir-.  mmc   !■>,    Miir.-lii-.n.  I'li-'l  nn  :',:>()(;  imm'-   ;hliuiltiii  \<>  ilic 
l.ciiuldii     I'.Acr    llo.-piial    iIui-':il:    ini    ycai>.  :u»l    a    latci'  niir    li\   (iiill>laiil 
lia      1  on  .'i.i  I.")  caM.-   acliiiilli-il  |u  |'ni>.-iaii    lin-|iiiaU   ihiriiii;    llu'   _\cai>   iVnin 

'I'lu-    Inllnwill-   aiT   lllr  ,-Ulli>lic>  (if    Muirlli.M.ll  ; 


\--i 

Sum 

l.cr  (i^Iiiiini  .1. 

iiidi 

I'rr  iciit 

fiHl.r 

.".   \  f:ll--      . 

.     17 

:', 

i7,i;'. 

B.tu.-,. 

11     .'.  iili.l   111  \.'ar-  ^ 
in    ■       I.-.  ■  ■• 

.    .  IK! 

;'.ii;i 

14 

IS 

4. -.I.-) 

i:,    ■■    •!»     ■• 

.  :Ai\ 

•Jli 

4.711 

•JO    ■■     -J."!      ■■ 

.    ('.la 

47 

;i.o.-> 

*■ 

U",    ■•     :'.n      ■■ 

:ll:l 

.")•_' 

l."..I.'l 

.. 

;In    ■■     :',.') 

;',*';! 

*>•> 

17,112 

:;."•    •■     in     ■■ 

:;7ii 

W> 

mL'   'Hi 

111    •■     I'l     ■■ 

.   .  "J'.c 

«7 

*".(  7'.i 

1.-,    •■     .Ml      ■■ 

.   .  -Ji-J 

:;■.!  I.-. 

K 

.'id    ■■     ."i.'i      ■• 

.   .  ivi 

7H 

•"iLMMl 

U 

."].'.    ■■    r,o     ■• 

.    .  Khi 

.-,1 

.'iMK) 

«• 

i;ii    ■■    i;.',     ■■ 

.     ,      HH 

4!i 

.",.',, ii« 

t> 

t;.'i   ■■    70     •■ 

.    .     A-1 

:iH 

liiiiiii 

711    ■■    T'l 

.    .     -'t 

17 

7n.So 

7-1    ■  ■     >n 

.    .       I'l 

a 

h:;.:::! 

(  P\.M' 

Nt      ■• 

*) 

IIKI.IK) 

,    .     ."ill 

7  la 

•-'•-'.(M) 

;!.'i(iii 

(iutl.-ladl^ 

•  >lali>li(  s  arc  ; 

Miilo. 

I',  laillcs. 

1'.  re.  Ill, 

i'cli  .m, 

1!   in  1111(1  1 '.  \cins  . 

•'111 

l,."i 

1.-,    ■■     -jn       ■■ 

.     .      ■'  - 

1   .-. 

"n    ■■     ;;(! 

>.  J 

lll.l 

:;n    ■■     In 
In    ■■    .'.n 

.     .   Kill 

ll.L' 

.    .  ai.'.i 

•.'n,'J 

(  K.  r 

.'lO    •  ■    ( ;n 
(id 

1-7 
■■7,  1 

4.1,  ■-' 

M\-  nwii  Iliad  rial.  (■(in>i>!inj  d'  41<l  ca^^  Irciitfil  in  l."<7!'  in  tlm  la/ari'lto 
al  Mnaliit.  \ii'l(lc(l.  accni'diiiL'  In  llic  ti-urt-.-  i  l'  my  a.->i>tMiil  Salniiinii.  llio 
liillnwiiiLi-  lunrlalilv  lor  tlii.-  dili'dcnt  a^is  ; 

i'(r((lil. 


Kr.iiii   In  1"  -II  )  i-di'-  . 
■jn  ■■  ::n  '  ■■ 
"      :;(i  ■.  m     •■ 
'•       in  ■■  .',11     ■• 


(ill  ■■  711 
711  ■    >n 


•J.'iO 

.■,.411 

•J(|,(H) 

4x.  -"li! 

(•,:>,.(■,:{ 

Ii-J..'i0 
Inn. (HI 


Tlir  iitt-rr|ii'iti'il  -tatcinclil  tin!  lllr  rtl'cct  iii'  aLIc  'HI  till'  ]ir(ii;ll(i-i-  i,< 
to  lie  atniliiitnl  111  lllr  iliiiiini-liiil  |i'i\\cr-  dt'  n-i-lancr  ai;-.iin-t  llir  niii  in- 
ni-'j.ini-m  anil  it-  lnvin-.  jii-t  a-  in  tlm  ntlmr  aciilr  inlnctimi.-^  di-ca.-i--.  i- 
a  niiTi-  |ilaliliiilr.  .\  iiiurli  iikii-i'  lanuildr  rna-nii  I'm'  llic  rajiid  v\-v  'd 
Miiirt.aliu-  .at'li  r  llir  :il:i'  ('t'  tiirl\-  i-  Ik  lie  lliiiinl  in  llir  ranliac  wcai^iir-s 
lli:it  i-  niiirli  iiidiv  iiridiiini  111  dnrinu  llii-  |ii  ridd  (d'  lilr  ;iiid  in  lln' 
|i:ilii((ii;,ir\  (■  iiii|i!i(aliiiii-.  c-iHci.illy  liy |i(i-tatic  iidliiniiiatidn,-,  ■lirc'lly 
(l(  pciidiail  n|i(iii  it. 


l'n(i<:.\(jsis  A.\h  MoirrMiTY. 


■  >Xi 


Till'  \\\\s\\  iuiirl;ilit\  iliii'iii;:  tlic  iicriml  Imiwciii  tliirty  ami  t'urty.  in 
iirniiiiftiipii  III  tliat  iili-c  r\((l  in  (itl'cr  aciiti'  inticliiiii>  di-ca-c-,  i-  jnul)- 
aliK  iliii'  In  llir  lar,  tliat  tvpliiis  t'cMi-,  \vlii<'li  |)i'ci(  ralily  altaiU-  tli<' 
iHHM'iT  (■la--r~,  ncncraliv  selects  lliu-e  inili\  idiiaU  who  liavc  -iitl'eiid 
iiiii-l  ill  llie  striitj;;'!!'  tor  existence  and  \\ho~c  ■tniii^tli  lias  liceii  .-a|i|Hil 
li\-  U(ii'r\',  vice,  and  ueiieral    de-titiitioii. 

A-  i-'^'ranU  tile  reinarkalile  dillei-enee-  in  the  iiiortaliu  ol)-er\ed 
dili'inu'  llie  tlii'ee  |iei-io(U  of  childhood,  we  -till  lack  the  lice;-- irv  data 
to  otVei' an  ex|ilan  ilion.  it  iniuht  lie  said  ot'  the  [icriod  lieiueen  the 
tenth  and  the  tit'leeiith  \iar  that  the  clinical  niateiial  is  selcctnl.  iiM>- 
niileli  as  onlv  children  ot'  <^ooil  c  pii-iitiiiion  and  nood  powers  ot'  re  i  l- 
ance  attain  that  a".'!' ;  and  as  regard-  the  lir-t  juriod,  the  death-rritc  is 
[icrceptiMy  iiicreast'd  hy  the  tiict  that  the  children  are  still  contendinL: 
with  the  ditliciilties  of  early  feedine-  and  with  iiilieritc<l  weakness  and 
the   like,  and    ha\e  not    \  et  dcvelopeil  a  -trone-  con-titiition. 

Next  in  importance  to  the  a^^e  are  occupation  and  mode  of  life. 
The  thcoiv  that  certain  eonditions  of  lite  and  occupations,  ow  inj.^  to  some 
inherent  favoraltle  or  iinfavoralile  eonditions,  exert  a  ]>ecnliar  inthience 
on  the  jiroLTiiosis  has  lieen  aliandoncd  in  the  liifh.t  of  more  recent  experi- 
ence. The  <'ll'cct  of  the-e  two  factor-  can  onlv  he  indirect,  and  they  ari' 
of  inrineiiee  onlv  in  so  tjir  as  they  determine  hodily  and  leeiital  over- 
exertion, insiitlicicnt  or  improper  I'ccdin^  and  modes  of  life,  and  ;;  neral 
har(i-lii|)s.  or  as  they  favnr  the  development  of  chronic  disease,  and  the 
ac(|iiirenieiit  of  passions  and  \  ices,  especiallv  alcoholism. 

The  markeil  intliieiu'c  to  he  altrihnteil  to  poverty,  disoase.  and  vice  in 
freiieral  is  ilhlstraled  hv  one  iif  Miirchisnirs  tallies,  in  wliicli  the  ■>'>iH'i  patients 
iidiiiitted  til  the  London  Fever  Hospital  aredivideil  into  three  cjasso  :  /■'/;■-/, 
those  ill  iriHid  eircuMistaiiees  ;  .■<iciiiirl,  lliose  in  moderately  i^"'"!  <ircinn.stunees  ; 
third,  the  pour.      The  results  are  as  follows: 


Fir-^t    class  . 
Sccnnd    ■* 
Tliini     •■      . 


A.lmitlv.l.  Iiic.l. 

'.It  i:. 

.     -Ji-.Tt  4'.I7 

~:\H  i'(l4 


I'.r  (int. 
It.Hll 

is.r. 
:;7.i;4 


The  mortalitv,  considered  with  rcfii'ence  to  social  status  and  oceiipa- 
tion,  is  fonnd  to  lie  ;;featcst  wherever  these  either  jierinanciitly  or  tenipo- 
ravily  ne<'essitate  a  eomliination  ot'  hodilv  and  mental  overexertion  with 
worrv,  care,  and  de-titntion.  Tiadcsmen  an<l  da\'  laliorcrs  attai'ked  liy 
the  di-ca-i'  while  out  of  work  and  without  a  home,  travelling''  ahoiit  the 
eonntrv  in  -earch  of  work  or  lixiiiir  in  a-\  Innis,  hnts,  or  overcrowded 
teiienient-,  die  in  ver\  ereat  nnmlicrs.  I'erson-  on  shiplioard.  in  i'am]i-, 
and  in  cilie-.  after  a  lone-  -iciic  are  al-o  under  similar  condition-  of' 
nnl'avoralile  proe-no-tic  oTiieii.      l'"or  many  year-  ••jc/nis  i-dsfriwis  j,il<- 


■'.jl| 

I  ^ 

I 

r 
V 


-—  n.  --•*. 


688 


ryrurs  ffviui. 


i-ltidlis,"  ••  Ijiiiliii.t  i-iircirinii,"  ;inil  ••  j'l />ri-i  iiiiidica"  liavr  liccii  kii(p\Mi 
;i-   ihi-   111(1^1    ilrtailcd    tiirm-   nf  the  di-ca^c. 

Ill  ictiaid  lij  llic  constitution,  llio~c  wlm  ai-f  naturally  (lcli<i(nt  in 
till-  ri-|Hri  (.r  have  iiiiiirc<l  their  litaliii  liy  liati  lial)it>  aii<l  an  iffi  jiilai' 
ami  ili--i|)atii|  iiumIc  i>\'  iiti'  ai'c,  rvcii  uitliuiil  fci^ai'il  tn  aur,  tn<i-l  lik(  Iv 
tu  --iiciiiinl)  I'l  till  (li-ia-o.  ALTain,  air(i|iiiii-iii  rxirl-  a  must  iianrt'iil 
iiilliiciici' :  "ill  |Mi- rriil.  i-  imt  tuo  jii^ji  an  t-tiiiiatc  lin' tlic  nn)iMalit\'  of 
(liiuilNai'<l-,  even  in  llin-c  lutwrcn  tlu'  aL;<-  nl    I  \\cnt\ -li  ve  aii<l  I'irlv. 

'I'liat  iliiniiic  ili-i'a-i--,  a»  liiiici'i  iiL-i.-.  ~y|iliili-.  malarial  cai'licxia, 
cliriniir  ^•a-trir  anil  intestinal  atliitiun^,  and  re<'ent  i'e<>iiver\'  Irnni  sexcro 
Ui'iile  iiit'eetions  di~eaMs,  appreeiaMy  augment  the  danger  nl' tyjilnis  t'eviT 
niH'd  hardiv  he  ineniinned. 

That  hiMlilvainl  mintal  iiverexertinti  exercises  a  marked  inHneiiee  (in 
tile  |iriiiriiii-.i-,  even  when  tiie  individual-  jidsse--  a  strung  eciii>titntii)n, 
are  Well  till  and  <>\'  a  t'avnrahle  age.  i-  -hnwn  hv  the  (act  that  in  all  the 
inure  e.\ten-i\e  e]iideniie>  an  Mini-iially  large  nnmlior  of  victims  were 
drawn  from  among  |)hy-ieian-,  lio~|iiial  attendants,  ministers,  and  otlieials 
in  pnhlie  institnlions. 

W  hether   mental   <  ion,  worry,  and   <'\eitement  without   aeeom- 

panying  hodily  distnrhanees  t<  nd  to  increase  the  danger  from  the  disease, 
as  ha-  liccn  iiisi-tcd  upon  partienlarly  hv  the  older  authors,  cannot  with 
certainty  he  determined,  hecause  it  i-  rari^K  possihie  to  estimate  tliuir 
intlueiiee   apai't    from    the  aliove-nientioned    l:i<'loi-s. 

Not  only  the  surroundings  of  the  patient  lietlire  he  was  attacked,  hut 
al-o  the  conditions  nndi'r  which  he  lives  during  his  illnc.-s,  have  an 
important  hearing  on  the  mortality.  i'roper  treatment  unipicstionahlv 
lower-  the  mortality-rate.  Among  experienced  hospital  phvsicians  it 
i-  generally  aeccptcd  that  any  di'lay  in  removing  the  jiatieiit  from  his 
r.ii-eralile  -(jciil  eouililion-  Into  the  moiv  favurahle  surroundings  of  the 
hospital  -eriou-lv  atl'eet-  the  proirno^i-. 

'I"he  etV((t  (.f  sex  oil  the  mortality  of  ty|)hus  fever  is  purposelv 
ti'eated  attli'did  nl'oiir  remai'l<-oi,  the  proguo-is.  Iiecanse  it  apparentlv 
doe-  not  I  \<'rt  aii\  direct  inilueiiee  upon  it.  The  lower  moilalitv 
oh-erved  amoTig  wnmeu  i-  cxjilained  hy  the  eirenm>tancc  that  the  female 
sex  is  much  lcs<  ex|io-e(|  to  the  dcleteiii ill-  iuHiiencc-  that  are  uatnrallv 
ineideiil  to  ilir  jil'c  iif  mall.  In  time-  <if  hardship,  lamiiie,  and  -icLiC, 
nvIhii  llie  iwo  -exi'-  -hare  e(|Uallv  in  want  and  nii-erv  and  the  epidemic 
s|)re:id-  to  the  permanent  pojinlation,  the  ditfercnc(-  in  the  niortalitv 
praeiically  di-appi  ar. 

( iiitl-laili'-  lalile.  Liiviii  nil  paifc  'i^li.  sliiiu-  clearly  the  liiirereiicc  in  the 
iiHirtality  nt'  l!ie  two  M-xe-.  e-pcciallv  ihn'iiii:  ail\anccil  age.      In  ihc  liiiiriu- 


ri:"i,\i).^is  AM)  Moirr.it.iry. 


589 


;ir\  .u  Ediiiliurirli.  IVin'ock  '  lust  1 14  oiii  nt'  'As  |i!itiiiits,  :'.77  nt"  u  lioin  ucrc 
inrii  ami  -"mI  wniufii.  Aiiiniiir  llic  f'alal  cases  tilt — ls,.'l  |nr  cent. — were 
men  ami  4> — 1  2.-i  |ier  cent. — wnmen.  In  1  •"<  17.  ilnrin;:  a  severe  epiileMUL' 
in  <ilas;ri>w.  ■>I.\  |ier  eiMit.  lit'  tile  nun  ami  (inlv  "_M(.7  |per  cent,  ut'tlie  women 
snccnnilieil  lo  tile  di^'ase.  Tin-  miirtalily  aimini:  .Miireliis(Jii's  :i.">l)(i  |iatienl.s, 
.■ilreaily  discusse'l  t'nim  nther  pninls  nf  ■  iew,  amoiiL'  wli.im  lliere  uere  almost 
as  manv  men  a.s  wnnuMi.  uas  'Jl.l>>  |ier  cent,  t'nr  the  men  and  lit. Ill  per  cent, 
fur  the  women. 

\\  liitliei'  certain  races  |)(is-e~s  ;i  (liniinislieil  [Miue''  (it"  rcsi-I.uiec  to  tlic 
<li-e:ise  i,  ;|  dilliciilt  i|iiostinii  tu  ilctcr'niiiie,  anil  we  liave  nil  means  nl' 
indL^iiii;  wlietlKi'  any  [lartieul  ir  nice  i~  mure  siiscepliliK'  tu  infi'ctiuii 
than  aiKitlier.  'I'lie  tint  that  where  the  cojoreii  ami  white  faces  are' 
attacked  -ide  hy  side  a  LTi'i'itcr  iiumlxT  of  the  ii)i'niei'  siicciiml)  tu  the 
di-ease  is  pmliaMy  due  tu  the  eireiirn~tatic(^  that  thev  are,  ti'eiierallv 
.xpeakintr.  I'laced  amid  much  more  imtliMirahle  extt'rnal  ,ind  social 
siirronndiiiirs. 

()f'no  le.ss  importance  tlian  the  aliove-mcntioned  I'aetors  which  deter- 
mine the  ireneral  niiirtality  are  those  t'eatiires  ut"  a  case  which  need  to  lie 
Considered  in    jndjr'iijr  of  the  proliahie  course  and  outcome. 

The  ipiostion  whether  the  mode  of  onset,  and  the  severity  of 
the   symptoms   durini;  the  stajre  of  invasion   atVord  anv  chic  to  tho 

I'uinr iiirse  of  the  disease  has  received  ditVerent  answers  from  ditVeront 

authorities.  Hiirh  fever  and  ^riiive  ireneral  manifestations  durin^r  tlii-' 
time  certainly  |iossess  no  pro;.aio>tic  -i^ruitieance.  Thev  arc  just  as 
likely  to  Usher  in  a  shift  of  4'ven  au  abortive  case  of  the  disease  as  a 
.>evei-e  on  .  On  the  other  hanil.  it  may  lie  said  that  a  mild  stai'-o  of 
inva-ion  aln\o>t  always  indicates  that  the  ^nliseinient  course  of  the  di— 
ca>e  will  also  he  mild.  \'ery  nirel\,  chietly  in  tiic  senile^  tofnis,  it  inav 
hajipen  that  a  com|iafatively  .piiet  a.nd  apparently  mild  initial  siap'  leads 
to  a  priiti'aeted  ilhn'-s  with  a  liital  i-esult. 

I)urin;:the  ~uli-eipieiit  course  lit' the  disease  certain  general  Symp- 
toms and  the  aition  of  individual  organs  and  ~vstem-  exert  a 
deci-ive   inllueui u    the   pruuno-i^. 

Anioiie;  the-e  ti/ature-.  the  nio-t  eiin-iiiruiius  niauifot.atiou  of  the 
fever,  the  elevation  in  lemper.ainrc  is  uiidouliieillv  ut'  LTeal  proirno>iie 
importance,  althoueh  it~  -ionificanee  has  in  many  res]ieet~  lieeii  exat:- 
irenited. 

\'ery  hiuh  temperature  duriuir  the  initial  staL^'  or  duriue-  the  lii--t 
week  does  not  absolutely  Ju-lity  the  expeilalioii  of  a  simiv  iliue~~  or 
even  a  fatal  termination.  On  the  other  hand,  the  pro-peet  i-  not  briuht 
il    a  coutinuod   or  cnutiuued    ii  initteut    fe\er,  with  a  verv  high  average 

'    (^lMtf,l   l,y    .MlirrllHi    11. 


."/Ml 


Tvriii  s  I  i:\i:n. 


'.*  \ 


m 


t(  iiipc  riiliin-,  [ici'-i-t-  .iIkt  the  tii'-I  \\(rk.  Coiivcr-clv.  a  t'aV(pr;ililo  pi-ci^r- 
Mo~i-  l.a-ii|  nil  ihi'  iii.ic  Tail  ill  ilir  tiiii|>i'rati]rc  alter  tlic  fii--t  wcik  i> 
lint  jii-lilialilr.  It  lia-  lucii  -liiivvn  \\\  -ivcral  cxuiiiiilc-  (  l''i:j-.  (i!i  and 
71  )  llial  filial  imilracliil  ca-c-  may  -Imw  a  iicr-i~tciitly  low  l"iii|itraImo 
(lining:  tin'  la-t  tl'U  day-,  or  cviii  a  «rik.  lirt'niT  dralli,  diiriiii,'  wliicli 
llnir   ..iliir   (iiiiiiioii-    -\  iii]i|i.iii-.   (■Miiiiniir   willidUt    alialctiiciit. 

Il  i-  \\i<\  |Hi"ililr  Id  -tall-  uilli  rrrlainly  wlicllicra  I'all  nl'  tcin|Mra- 
liiic  111  llic  -ivciilli  day,  wliirli,  ac vdicliii;.''  Id  W'liridcrlirli,  i~  tv|ii<',il  ot' 
a  laN'inililc  iM-r,  may  lie  ciiii-idrn-d  a  lasuralilc  |iniL:iii>-lii'  .-i;.'ii.  Wv- 
sdiially,  I  lia\c  raivly  met  wiili  ilii-  iiliciKimciinn.  (  )ii  ihc  hiIk.,-  lia.nd, 
marked  irmi— idii<  ;iiiil  iiitt'rini,--iiin>  (icciiiTiiii.^  early  nrc  mulcitiiitedK 
(il    ta\(iral)le   umeii. 

1  he  aetiiiii  111'  tile  eireiilalory  driraii-  is  cif  I'ar  j.M'caler  im|(nrtaii<'e 
ill  the  |)run|ii,-i-,  and  alliird^  a  reJiaWle  mean-  nt'  jildiiiiii:  the  coiiisc 
lit  tile  di-ea-e.  A-  lia-  iieeii  -tatiil  el>e\vliere,  tile  piiNe  in  t\]illlls 
lever,  lint  'iiilv  in  wiiiiieii,  eliildreii,  and  nld  |>ei'-iin-,  Kiit  al-n  in  vi^iir- 
.111-  men,  i-  urieii  ]>rii|iiirtiiiiialely  Ncry  ra|)id,  iiotli  earlv  in  tlie  entir.-e 
lit'  the  di-ea-e  and  during'-  ilie  entire  telirile  [leriiHl,  the  plienonicniin 
iieiiiL;-  ill  aeenrd  \\  itii  the  \  inleiiee  iit  the  ninde  ut  iin-et  and  |ire-pntinjr  a 
certain  enntia-t  tuwliat  i-  iii)-er\ cd  in  typhiiid  fever.  'I'lie  pulsf-rate 
il>elt',  althniiiih  it  iiidieate-  the  early  ;md  distiiiet  invul vcmelit  of  tlic 
lii'arl,  i<  df  e\cn  le--  impiirtaiiee  than  nther  iiualitics  of  tiic  pnlse,  fspo- 
eialh  Vdlunie,  teii-iuii,  and  reixidai'ity.  The  earliei-  the  jiiilse  iieeumes 
xift  and  easily  ciiinpre— ilile,  or  iinei|iial  and  il're;;iilar,  the  more  nnfa- 
voi-al)le  the  ]iroiriio-i-.  Karly  irreirnlarity  of  the  pulse  I  believe  to  lie 
an  e-peeially  nsefiil  -i;.rii.  It  iniist,  lio\vev<'r,  alwavs  he  renienitx'red 
that  reeiixcrv  lia»  lieeii  known  to  oeei.r  even  in  ea-es  in  wliieli  the  iinlse 
\\a-  liarely  |>erce|)til)le  for  days,  and  so  i-apid  tliat  it  could  liardiv  i)e 
ooniited# 

Next  in  iiiiportanee  to  tile  ijcliavior  of  the  eireiilatorv  svsteiii  from 
:i  |M'oi.rnostir  point  ot'  view  i-  that  of  the  nervous  system.  It  is  evident 
that  -evere  di-tmliaiiee-  of  the  central  nervous  system  indicate  that  the 
elicit  of  the  toxin  lia-  liicii  p.irticiilarly  marked  or  thai  the  iinlividiiars 
power  df  rcsi.-tancc  is  miicli  rcdneeil  ;  and  thus  the  cai'licr  the  a]ipcar- 
aiiee  dt'  iiervon-  svni])toms,  the  more  iinfavoraMe  the  proirnosis. 

One  -lioiiKl  lie  p.irticiilarly  1.1-iiardeil  in  iiiie'<  prot'iiosi-  when  stupor 
and  coma  iii;iiiife-l  iheiii-elve-  carK'.  .'^iieli  c.-iscs  arc  n-iiallv  graver 
than  ca-e-  in  which  the  mind  i-  le--  m.arkediv  .•itl'ccted,  e\cii  than  those 
in  which  llieie  i-  violeiil  delirium  in  the  evcnin'j  and  dnrinj,''  the  nii;hl. 

( 'iiiii|ilclc  iii-omnia  iiianife-tiiii.''  it-elf  diiriii:.'-  the  tir-t  davs  nf  the 
disca-c   wa-   ju-tly   con-idercd   a  \cry  sii-picioii-   sxniptom    hv  the   c.ldcr 


t ;. 


l'l:(/(,.\(fMS  AM)   MnUlM.iry. 


rm 


;iiilli..r-.  It  i-  not  iiitV(i|ii.'iitl\  ^i  |)ivciii-c,r  lo  \\n-  !hi|)(li—  nianifi -t:i- 
liiiii  111    llir  ili-ca-c  llial   li:i-  Ih'cii  :i]i|1\   i|<--i;^ii:il((l  cuiLi-x  i^il. 

.M:ill\  |ili\ -iciiiii-  I.  lid  llir  (HciiiTcMcc  ol'  -||  I  i-ii  1|  ||-  !iii(  I  iriiini, 
(•:ir|)linliiL;\ .    ami    cIimii  ii     l\\  ilcliiiiu-    ami    linndi--   a-   aiiioiin    ilic    nin-t 

(laiiuci-iiii-    -i^ii-,  ami    it    i-   cirlaiiily  true   that    tliixdcciii |\    in    \<i'\ 

scvri'c  ca-c-.  Ili(-.c  -\ni|>tiiin-  ilu  m>t.  Iiuvmai'I-,  all'cci  tlic  |ii(ii.ni(i-i-  in 
tlir  -ainc  lAtriii  a-,  tlicv  dn  in  t\|ili(n(l  trxcr.  <  )u  iiitr  t(i  tlir  -(■If-liinitcil 
am'    |-rlati\(ly   -liort    dnratinn    (if  t\  |ilin--    i'cvcr,    the    |>ali(nt    i-   alilr    tu 

witii-tami.  until  the  cii'.iin-cnrc  of  ih.'   ni-i-,  iiioil,ii|   ( ditinn-.  that,  if 

they  wcrr  to  contiiiiir  loiiLivr.  umiiil  cri-tainly   kill  liiin. 

ficiirral   coiivnl-ioii.-  arc  ot'  iiiitavdialilc  mm  ii.       Tlic  {.Teat  iiiajoritv 

of  adults  att  u'krd  liy  < viil-ioii-  die  ;   w  licrca-  cliildrcii,  w  ho,  a~  i-  well 

known,  arc  attacked  hy  coii\nl~ion-  in  a  larjrc  niiiniicr  ot'  iiinch  Jos 
jjjiiivc  <-ondition-.,  arc  more  likclv  to  fccovcr. 

Altiioiitrh  \vc  ate  -till  ill  the  dafk  in  rc;:ai-d  to  the  causes  of  many 
clianirc"  in  the  |in|iil  in  typhns  t'ever,  ue  know  from  ilinical  ex|)ericnee 
that  a  tew  of  them  are  ot'  iindoiihtcd  value  in  protein »is.  In  -e\ere 
eases  diiriii^r  the  heiirht  of  the  disea.-e  and,  what  is  even  worse,  diirin^r 
the  (ir-t  week,  a  very  -liii:jpi,|i  reaction  to  li<rht  is  often  uh-erved.  If 
this  is  accompanied  iiy  a  hi;.di  de^'icc  ot' myo-i-  |)rodnciii;^  a  "  piii-iioiiit  " 
pupil,  the  comhination  i>  of  the  wor-t  sii.riiitieance.  This  phenomenon, 
(lcsi^rnatc<l    \)\    (iraves    and    the   older    Kn;;li-li    authors   as   "pin-hole 

pupil,"    I    liavi'    oltscrved    mo-;   ot'tcii    in    case.-    that    eiKlcd    in    na- 

vijril. 

The  e(iiL(iitioii  of  the  respiratory  orfrans  deserves  some  attention  in 
(ieterminiiijr  the  projrno.-is.  Iieferenee  has  already  l.een  made  to  the 
severe  idii-e<|iiciice- that  may  he  expected  to  follow  anv  marked  involve- 
nient  of  the  larynx  f;>r  either  the  future  health  or  the  life  of  the  patient. 
Ti,  ■  -iv'iiticance  of  catarrhal  and  pulmonary  affections  varices  w  iddv 
and  depends  chictly  on  the  ap'  of  the  |)atient.  Whereas  children  and 
youiiir  hcaltliy  adiilt>  under  Iwenty-tive  years  of  aire  iisiiallv  hear  an 
extensive  attack  of  liroiichitis  or  |)nenmoni:'  fairly  well,  the-c  eoinpli- 
cntions  seriously  threaten  th,    life  of"  ohier  persons. 

It  is  not  too  much  to  siy  that  at'ter  the  aj^c  of  flirtv  mo-t  <if  the 
deaths  aiv  directly  or  indirectly  attrihiitahle  to  extensive  hnmchiti--  with 

lobular   pneumonia,  to    liy])<.stases,  or   to   the   freipient   nplication   of 

lobar  pncn:nonia. 

The  condition  of  the  diircstive  offr.'.ns  i-  of  >nbordiiiite  importance, 
l)oth  fi-oni  a  clinical  ami  proLHiostic  piint  of  xicw.  Diarrhei  i-  rre, 
b'lt  I  have  met  with  it  both  in  mild  and  in  severe  ca-es.  ('ompli(v- 
tions    with    (ly-eiiteiic    phenomena,    which    have    rareiv    been    obserx  ed 


till 


692 


TV  I  ■III. -^  II  III:. 


i 


«j*-v*f.- 


sV-' 


4 


iliii-iriLT  l!ir  in.,-!  iv.,ni  .  |.i,l,  ini. -,  wviK-  iii-ll\  ri-i::ir'lr(  I  ii-  jrraxc  :ii  ri- 
iliiil-  li\    ihc  i.Mi  !■  :iiiilii,iv  I  K.inillicr,   I't-i.-i  iik,  :iii.|  ciiIh  r^i. 

.M\   I A|ii  III ■    IcaiU  IMC  |o  ir.jani  -cxii-c    iiirlii.ri-iii.  uliidi  i-  (lirtn- 

li:ilrl\    a  rail    iM'ciini  HIT  ami  i-  iiiiiloiililcclK    llir  ri-.iilt  ufa  -ixiii    iiilip\- 

ii'.ili I'  till'    iiir\i-    -ii|i|il\  ill;;    llir  iiiii-iMilar  wall- of  llir  int. -lino,  ;i> 

111'   till'  v^o|■-l   |irnL:iiii-tir  -iiillitiralirr. 

I'll'-  I'liidili I'  ill.'    iiriiii'.  liiilli    pliN-iial    ami    rln  inii  al.  alliniU  I  lie 

lili\-i.iaii    iiiaiiv  \aliiaMc   liint-.       A    niarknl    .liiiiiiiiiii.,ii  in  ihr   ^m m 

"I     lll'iii.',    or    loinplilc    anuria    la-liiin     maiiv     ila\-.    imliiai.-    a    .l.oi.r 

III    .•aniiai-  wrakn.--   lliat    .Miiliially  |.io\.-    I'aial    tu  niaii\    |iali.'nl ti> 

ihr  iil.l.  r  nm-  al ~i  w  iilidiu  r\.'t.|iiii,ii.       A  iMi-i  fill  ilit.Tininali f  llic 

aimmiil  III'  alliiiniin    in    tli.'   nriii.'    i-   imi   will i    it-    ini|)iirtaiiri'  fm-  ih.. 

|iri'M|ii,-i-.      'I'lir  larly  a|i|i.Mranri'  ut' .nii-iilir  ,1,1,.  .n nil-  n|' allniniin  i- 

.lii-rrviij  ii|il\  III  -.A-.T.'  CM-.-.  If.  in  ail.jitiiiii.  tliciv  i-  licinalniia.  witli 
the  iiii,Tii-cii|iic  tiiiiliim-  cliar.actcii-iic  nf  iic|iliiiii-,  mic  lia-  tu  .leal  with 
a  \iv\  ui-a\c  .■.ini|ili.-atiiin.  .Vimni;;  all  .'a-c-  in  |i.r-,in-  li.twc.ii  tliirtv 
ami  liifty  y.^if- ul'  ,iu.'  vvilli  m'|iliriti-  tii.'  iiiajmitx  .ii.' ;  aiminj.'-  |iati.iit> 
.if  imirc  aiKaiic.d  -a'jh  rccnx.rv  i-  .ji-tinclly  .•.\i-c|(iiiiiial.  It  -cciii-  t.i 
tu.'  i-allicf  -i;;nificaiit  in  tlii-  ciiiimctiun  tli.it  in  all  iii\  liital  .a-.',-,  cmm  iit- 
iliL"'  a  few  ill  wlii.'li  dcalli  \>a-  .liic  in  -pccial  .ac.a.j.ait-.  tlic  iiriiic  |).r-i,t- 
cntly  -Imwcl  a  laiyc  ainuiint  uf  .ail-ninin. 

Mii.'li  |irii;;n.i-lic  iin|(ii|-taii.'.'  ha-  lic.n  atlriliiit.'.]  liv  niaii\-  aiith.ir-  t.) 
tlic  ciiKlitiiin  .if  the  -kin,  liy  tli.'  ul.ler  writ. a-  partK  lui'aii-.'  tlii'v  w.rt' 
still  nil. let'  ilw  inriiicn.-.'  nf  th.'  Iiiiin.iral  llic.iri.s  .if  .li-ca-c.  I'cr-.inallv 
I  li.'li.vc  that  tlic  iiii|Mirtancc  nt'  the  .•iitaiie.iii-  inaiiif.-lati.iii-  ha-  lieeii 
f:reatly  e\ai:L:.Tate<i.  I  eaniKit  hriuu'  iny-elf  t.i  atrr.'c  with  tli.i-e  \»li(> 
l)eliev.'  tli.it  the  aliiindaili'i'  ul'  the  l.i-e.il.iiis  nisli  is  iir.ip.ifti.i'ia!  to 
the  -e\(Mily  nt'  th.-  ivi-e.  It  eaniint  lie  lienie.l  that  a  nal.',  -.•ai:t\-, 
|-:i|)i.lly  .li-,i|i|)cafiiiir  ni^li  i-  f.nm.l  in.irc  fre(|iiciitl\  in  mild  .a-c-  ;  Imt 
ill  any  e|)i.leniic  exaiiipl.'s  are  fiiiind  .it'  very  severe  and  fatal  ca-.-  in 
wliicli  tlie  typical  ni-e.i|.iiis  ni-h  was  -i.iw  <i  a|i|i.ar  and  d.vcl.iiKd 
iiii]ierfe<'tiy  nr  cv.  II  r.inaliii'.j  alt.ijivth.a-  aliseiit.  When  it  i-  r.inetii- 
li.'r.'d,  iii.ir.'.iNcr,  that  niaiiy  nf  the  ali.irtivc  ca-c-  with  -.v.fc  .m-et 
often  pre-ent  frniii  th.'  iietriniiiiiir  a  well-inarkeij  anil  c\teii-i\e  rash,  I 
tliink  it  will  he  a.hnilt.'d  that  tlic  eiii|)ti.)ii  in  itselt'  i^  .if  little  value  ill 
<let.'riiiiniiij:'  th.'  |)rntrn.isi-. 

'Pile  luiii.irrha^H.'  plieiioiiicna,  on  the  otlier  iiaiid,  are  of  mneh  more 
scri.ins  iiii]).irt.  Karly  and  exten-ive  heiii.irrha^ni'  traii-tiirnuition  of  tlie 
rn-c— puts,  and  particularly  the  nii'iirrciic.'  nf  |,cte<hiai  ;iiid  extensive 
heinorrliayr.'-  iiii.lcr  the  -kin  and  in  th.'  Mili.'iitaii.'.ms  I'.'lhilar  tis.-iie,  as 
has  already  Ix'cn   stated,  is  alway- a  jrrax-.'  -it.'-ii.      (  ascs  that   present    in 


/7.''/',.Vos/.s    .1  V/y    Mill:  I  I  /  //■) 


593 


II-   -\  iii|iiip|ii 

\r|||l|;lll\      (licil 


;i'l'iiti-ll  -.iliul.  I,.-  ..111,,.  -ki„,  ij|,  ,,j-  ,i„.  ,„,-,..  ,,,,-.  lii,-,-i-,  ;y„l  to,-  Miv 
.•|lll|ii~t   !•(  rliiiii    III  i'ii>l   l:il:ilK. 

'"  '"iiiicril.,,,   uiil,    il„.   i\|,||,,-  \\yvv  r:i-l,   :i,m|    ii-  -,,•, „i,|;,rv  allcni- 

''""-■  lll'llli..ll  lllll-l  Im'  in.'l.lr  n|-  l|,c  (lillll-,.  ,\:;|„,-|-  ..f  ill,'  lii,-,.  an, I 
liaiKl-  thai,  liia-inii.li  a-  it  iii,li,al,-  ,ai',lia,'  u.akii,— .  1-  a  |,arli,-ii- 
'■"•ly    l':i'l     -iun.         I      lia\,'    raivl^     -,  .  ii    a     |iati<iil     uill,     ihj,    -\ 

!■' ^'i'-       A     li"     uIk,    at    lir-t    |ir,>iiii-,,|    t,,    w,  i     „, 

,i|    -.iiiif    :;i'a\,'    ,.>ln|)lii'ati.p|i. 

■^ "-    ll"'    ii'ii'.\    -,\-t,nii,-   an, I    ,,rt;ani,-   ili-,'a-,-    -,,  (ar    ivtlrnHl    t,, 

'''■"    '"■'>    -li"n,i,    ih,.    Hi;.  ,,f  ,1,,,    |,ati,,ii,  il,,.,-,.   ;,,,,    „,„„,   ,1,.,,    ,„.,,.  |„, 

iv-ar,!,.;  a-  !,.,•  a li/alinn-  ,.flli,.  ,|i.,,iv,  uhil,'  ,.lli,.|-~  ar,'  ,■ |)li,'ali,,n^  in 

iIk'  -tri.l  „.n-,.  ,,f  i|„.  u,,r.|.  1,  i,.  ,,|-  ,.,„ir-,,  ini,„,--il,|,.  |,,  ,|,.;,„-  ^ 
-liMq.  lin,.  ,,f  ,|,aii;;ivaliM„  l„.|u,.,ai  i),,.  ,„,,  ^r«ii|,-.  It  i-  ,,,,1  t,K,  ,nii,'li 
I"  -nv,  li,,„,.v,.r,  tliat  th,.  till,.  ,nni|,li,'ati,,ii~  ,A,rt    a  -[MMaal  intliwn,.,.  mi 

til'     |)i-,,-ii.,H-,  ina-i 'Il  a-    lli,.y  ,-laiiii    many  vi.tini.   att,f  tlii'  |)rimaiy 

(Im'!..,'  I,a>  Im,.,,  -ii,M-,.-li,lly  ,,v,iv,,in,..  In  tlii-  ,nnii,vti,M>  1.1  ni",- 
'■'■'"'I"'  '!"•  na,I.T,,f  il„.  ^r,,v,.  „.,|„,|.  in  tl,..  iv^i,,i,  ,,f  il„.  |.liafvnx 
■""'     ''".'"^'    -'I-'-'"    "I'    '!"■    Inn-.     |>iii'iil,.nt    aii,|     ii,.,T,,4i,-    |,l,.Mri.v, 

"'■I''"'"'-'    l'''l'~ "    "'■    'II-'   -l^m.    aii.l    iiiali-iiant     lorin-  ,,|'    .Icaihitn-.' 

(iiitt-ta.ll^   iv|),.;,f,lly  .|ii,,t.',|-tati-ti,-  IV,, in  tli.'  I'ni-.lan  li,,~|,ital^ -li,,u 

tli.-it    in  ,,n..-~ixth  ,.f  7!t(i    Ctal  ,.,.-   ,l..at ,.„m..|    aft.T   tl...    titt,...nl|, 

-lay  -.r  III,'  ,liM.a-.-.  aii,i  in  half  ,,!'  tli,.>,.  ,|,,,th  ,„vunv,l  .vrn  mIut  the 
tliiiticth   day. 

fn    tl...  t;,iv-oii.j,r   paircs  th,.   |,r,,>|Kvt  ,,f  iv,,v.m-v  fnmi   tvpl.tis  fivor 

Im-  lM.,.n   >h„w„   t,,  I.,,  in  -...ural   ,|iiit,.  .i;l,,„inv,  aiul   tl...   n.anv  ,h ,ts 

thfiat.nin-  the   lifi.  ..f  th,.  patiint    in  all  th,.   -ta-..s  ,,f  th..  .lis.'.as,.   lmv,> 

IH...I.  ..niniMfat,.,!  ;   in  ..nn.li.M.Mi,  vv  .nay  a.l.l  a  s,.nH.what ■,.  ..luvritifr 

"ihscrvati  :n. 

Typhn-    r..v..r,    lik,.    ,.n,.nn„,nia    an.l    a    iW  .ith.r   a.iit,.   inr<.,.ti,,n>. 
lK.|,.n-  t..   th,.  ,li...aM.s    ..i.ara..t..n/..,l    l.v  a    f..|ativ..|v    sh„rt    .Inrati.m' 

"'•■   • ■'•"'    l"^"-''^^   "'"'!">-'   l-y  ''nsis,    th,.   ..xtf.., iatc  ..f  whi,.h   ..aii 

ahn,,>t    aluay-    l„.    ,l,.t,.nnii,..l    l„.(;.,vhan.l.      In    th..    vrv    w...-st    an.l 

■•IM'."-''"tly  -l.-|..fat..   .a^.'s  „n..  may  still  .tinii,.  t,.  h,.]),."}',,,-  th.'  .Tisis 

an.l  nitiinat,.  n.,.„v..i-y.  an.l  th,.  latt...-  ,.an  „((....  1...  ,iir..,.tlv  attril.nt..!  t.. 
-an.fnl  nin-Mniran.l  -kilfi.l  han.llin^r  „f  th,.  ,,ati,.nt  .lnrinjr",.„ila,,s...  Th,' 
tv-nlar  •..•If-liinit...!  .•„„,-..  „f  tl,..  .Iis..a.,.  pai'tlv  uWWt.  its  scvi-ritv  and 
its  tlan<r,.r. 


Illli: 

m 


DIA(j.\OSIS. 

General  Considerations.     Wh.  n.  \.r  ii  I-  |.M-il,l,.  ,,.  ,,|,Mrvi'  :i 

\\.'ll-iiiaik,d,    ivpi.al    r.i-r   ..f    iN|,liii-    |,.\,.i     ilnnii-; I    ..r   .luring    ilir 

-'''■•"'■'■  I'-i"  ■•'  'li'  '"iirM,  tlh  ,liai.r|in-i-  |,iv-,i,i-  \,r\  fru  dilti.-iili  i,-. 
Km'Ii  :ii  thr  iMuiiiiiiii-  uf  ill,.  ,|i.,a-c.  ..r  atlrr  a  liw  ila\-'  ..I,mm\  al  inn 
.liiriii-  til,  lal.i-  -la-.-,  u  ill,,, in  aii\  kn..u  1, ■,!::,.,  .f  ||„.  |,ivvi.,ii-  lii-|..r\, 
it    i-  ,,11,  II  ,|,ij|,.   ,.a-\    I,,  iv,-,,-i,i/,.   il„    , I, -,:,-,.   iC  ,,ii  ,.|,i,|,  ini,.    ,  xi-N.  aihl 

'•'   '•   '-  '■ ''  'I'-"   '!"■  "■"""It    lia-   Im.ii    ill    ,.|,,-,.    ivlalioii-  uiili    |,ali,ail- 

'""'""'"'■'lb  -ntrnaii-  lr,„„  is,, I,,,.  H-v,,-,  .,r  if  h,.  ha-  I,,.,,,  in  tlM-ir 
Ihiii-i-   ,ir    ii-nl    tlir    -am,'    lit,  ii-iU. 

If.  huvv.Arr.  uc  lia\i'  I,.  ,|,,il  uilh  an  i-,,lalr,|  ,,,~r.  ulii,li  i-  ;M.r|ia|i- 
tlic    tiiM     llial    lia-    ,Kviinv,|    in    lli,'   ,li-iri,t,    ,,|-    if  ih,.   ,li-,-a-r    )iiv-,nl-. 

"""-"•''    !''"■ iiiia   :"itl    thr   .-oiir-,.  i-   irn-nlai'.  tin-   ,lia-ii,,H-    mav   lir 

iimr,-   (iilliiiili. 

'ii   ''"■    li'i-inn-  i-a- criw..   .Aaniinal  i,.ii-  \m11    imivK    .•iiaM,-    [\[i- 

l>li\Hciaii  1. 1  aia'i\,.  at  a  (hlliiii,-  ,,|.iiii.iii.  an<l  it'  th,-  ,'a-,.  Iia-  liccii  iiii.l,r 
nli-crvati.iii -,.nic  tiiii,'.  Iir  uill  ivali/c  tli,.  tii,     that  l\  |,liii- tlvcr  .lu,-  ii,it 

|>iv-,.|ii    an\    |iatli..i;n,.ninnir    train    (,f  ~\  ni|.l..'    ..  I.iii    that    thr    i |,.  ,,f 

oiix'l  and  >iil,-i,!rii(c  of  ill,,  \arioii-  -\  iii|itnniN  a-  will  a-  tliiir  ,-,ha- 
i-ti'iici'  anil  (liiratii.n.  ha\i  iiii|M, riant  |iart-  in  the  |>r(Mliii'ii,in  nf  tli,. 
(■iiarai-tcri-tic    clinical    |iiiiiirc. 

Kvcii  iliiriiitr  an  c|iiiliiiiic  iimi-iial  nianitl -tati,,n- ,.f  the  ,li-ca-c  inav 
<aii-c  i:rcat  (liauim-ti,-  <lit1ii-iiltv.  ,,r  i\,ai  make  i;  ,|niic  ini|),,"il,|,.  t,, 
I'cc, i;_riii/c   the   (li-ca-c. 

Kiioiiiih  ha-  Ihcii  -aid  ahniil  ll  ■  inai  kcd  inf-ci  i,,ii-ii,._,  ,,f  ,1,,.  ,11,,.;,,,. 
and  the  iiiiiv(T-al  |)rcdi-|K.-iti..ii  I'u  in,l  at  all  aL'-i-  and  under  the  er,.;ii,.>t 
v.afictv  (if  e\t,.rnal  cireiiin-tance-    t.,  -Ii,,«    th,.    ini|M,rtance  ..f  niakiii::  :i 

.•linical  dia-n..-i-    ;i-  - i    a-    [M.-iM,..  n..t    only  f.r  th,-  |,ati,ait     hiin-elf, 

liiil  to  a  inii.Oi  -reater  dc-ive  f..i'  th,,-,.  -nrroiiiKliiiL:  him  and  for  the 
ciilire    |io|inlation    ot'  th,.    t,,\\ ■   ,li-iriei. 

I'.veii  the  morliid  anatomy,  uhkli  i,,  niaiix  iiitliti.iii^  ,11-,.;,-,.-  alVord- 
llie  iiicaii-  ot'  de<a,lin-  a  d,,iilitfiil  ,.a-c.  i-  not  in  it-,. It'  -iitlii.iiin  |,,  |.|ear 
ii|i  th,.  diaeno-i-  ill  a  doiil.tfiil  ,.a-i..       It  ha-  licen -hown  that  no  di-tin<'t 

allc'i-atioii-    j.ecidiar   to    the   iii-,.a-e   are    I'oiinij    in    || adaxir.    and    the 

aiito|,-y  in  il-elf  raivly  p. veal-  more  iiif,,rmation  than  that  d<.alh  lia> 
occurred    a>   the    I'cMilt    of  -oine   acute    inli-ctioiis   disciwc. 


'  -  (.„• 


JilM,.\(i.'sl\  -,,- 

'""      '"""I"    '■■   'I' -I'Mtr   a    |.Mtli.,-,.„i,.    .nirn.H„V':.iiiMi.    u  1.1,1, 

''"'"'''  '"■''''"  "•"■  •"  'lia-Mo-,.  il,,.  ,|i„,,,„    |,.„  .,.  ,;,,.  ,:,i|,.,|  ,,„  , ^^j  ^  ,. 

ih~Min,n,.Mt.,i,l,    .litli,  ,ilh.  -.      I'n.ti,  ul,;,i  l,a-  I,,.,,  sn.l  mI i  tl„.  |,n  ,.„i 

-I. If  ..rthr  ,|M<-liMn    It    Ulll    I,,.   -,,.„    iImI    u,.   MIV    -till    VMrllollt    ;i,IN     kii-.ul- 
.■-!-.•  .,f    thr    ||„,.t    r-,.|,|l;|l    ,|;il  I.         It     I-     pn.lMMr   tll.H    f,.,-   -,„,„. "(i,,,,.     u,. 

"''■'"    ''^''"    '"    '''i"'"!    liiii''^'!    "l-.iv:,th,„    mIoi,,,  atiil    ll .,,i,,„ 

IMIIU-I.IK    |,iv-.  lit-  il-i  ir   «|„lli,f  tli.iv  aiVMM.N    nlialilr.lat; u|,irl,  t., 

Im-i.  :i  .liauiiM-i-  iliiiin-  th.-  initial  -la-r  ,,f  t.vi.liu-  (rvrr.      'ri,,.  ,.i,i,.,.ii ,,. 
M  -n|ito,„-  al.,11,,  „  „|„„i|  aiiv  IwimuImI-,.  of  tli-  ,Ai-t.n,v  ,,f  an  .■|,'i,|,.„ii,. 

""■    '"'"■'•    I il"liM.-   nC   ini;.,.tin,i.  iliaMr    ■    at    h,-t    I.,    Mlakr    nlllv    a 

I'luvi-inna!    .Ii:,-i„,-i-.       ill  ,ii,,-|    .a^.'-  it   i-   ini|.,,„iM,    in  -a>    iii,,iv  ||,ai, 
that    -diiir    ariilr    iulr.t  Imii-    di-.a-.-    i-    ilii|ii>M.iili::. 

■I'll''  tn-l  iii,|...itaiit  ,li-a-,  -  m  tlir  .Jitli  iviil  iai  .lia-iiu-i-  aiv  tli,.  a.-iit.. 
(•\;mtli...iiata,  ,-|».,-ialK  MMail-|,.,v  aiwl  -,,irN  t  f.v.r,  .vla|.-iii-  tivrr, 
<-ivl.in-,,iMal  iiirniii-iti-,  aii.l  .n  |.tu^niii,.  -,.|,ii,.,,|,v  ,.,„ia— rii,i,.|i  inniv 
Par,  ly    typlhiiil    tl\ri-. 

Differential  Diajjnosis  in  Initial  Stage. ^-ilir  initial  -ta-.' 

of  t>|.liii-.  r.vrr  |,iv-,iit-  many  |„,int~  nf  iv-.niManr,.  (.,  tliat  of  Small- 
pox :    tin    -an,,.  -,i,|,i,,,  ,,i,-,.,  „i,|,  ,.|,i||,,  .,  ,.,|,i,||,   ..^^j,,^^  |,v,vxia  will.. 

'""    '"•    "''•'    '-'l^'tivrly    -lijit    .vnii-M,m.,  ,.arK,   |„-,,t; l"  |.>--t,^,ti,m, 

^'■"■''''  1'^''"  '"  ''"•  '"-^"l  =""'  liml.-,  an,|  -|,l..:,i,.  .„la.-,.ni,.nt.  wlii.li 
iiMially  ran  !»■  .l.ni,,n-trai.,|  at  (li..  l..-imiin-  ,,r  tli,.  tir-t  vMvk  ,,f  the 
(li-,'a-c. 

'I'll''  tln-t  that  pain  in  tli,-  l.a.'k  i-  a  inii.li  ni,,n.  tV,.,ii,.nt  an,|  vi,,l,.,.t 
Min|.t,in.  ill  th,.  initial  Ma-,.  ..f  variola  than  in  that  of  tvphiis  f,.v.T  j.  „f 
>lii:lit  .lia-l.,.Mi,-  -i-nilira,,..,.,  t;,|-  th..  -y,n,,t„iii  ii,  i,,,.],"  |.  „„i„,,  ,.,„„,,, 
:incl  1-  i„,t  raivK  al.-,.|,t  in  th..  niiM.,-  timn-  .,f  Mi,all-|„,x.  ()„'ih.. 
""'"■I-  liMn.i,  Ih,.  larly  ap|M.aran,.,.  ,,f  an  initial  -..arlatinal  ra-h  '  .„.  th.. 
thitrh  aii.l  npp..r  arm  i-  .,f  ..,m..  iinp.iitan,,.  aii.l  -tron.dv  p.,iiit,  t- 
M„all-p,,v.  a.  it  i-  parti..||larly  lik..ly  m  ,„.,,„.  i„  ,|,„  .,,,,,,,.  ,;,^,„^  ,,,■ 
that  ,li-..aM.  an,|  ,1,,,.-  ii,,t  ......nr  ,.i,|„,,  ;„  „.|,,„,,  ,;,^,,,.  ,,,.  -^^  .^_^^.  ^  j,^^_^.  ^^^. 

''"■  ^"■'"•'  i"''-'i""-  'li-'^'-'-.      <  »M  tl„.  „tli,.r  han.i.  an  initial  nira-lv  ni.|, 

'^  "'    -'■•"'"'">y    irnportan.....      Wrv ar    an.l    rapi.llv  -li-api.rarin.r 

rasli..>  „..,.,ir,  a>  w,.  hav,.  -,.,.n,  -l„,,,|v  |„  ,;,,,.  „,  ,,;„,  ,,,,  „,,,  .,|,|,,,.,,;_ 
:'"<•'■-!  th..  >p....iti..  typhii-  f..v..rr.w..-~p,„-:  l,„t  tho  .lia-n,M>  i,  ..„,„ 
■■l.'ar.'.l  up  l.y  th..  app..aran.-..  ,,f  th..  latt.r  ,.r  l.y  th..  ..ruptioii  .,f  tvpi-al 
Miiali-p,,x  l..-i,,ii-.,|„,  iiatur..  an.!  ,iistril,iiti„i.  of  w|.i..h  a.v  ,.|.ai-a,.f  ri<ti.. 
IV. .11  .liirin;r  the  initial  >taL''i'. 

I'inallv,  it  may  \,r  w.ll  to  |Kiint  ..nt  h.w  <Iii:htlv  th..  fli....  i-  i„volv..| 
'(■,„„,.„•.■   r„r.,ln„;.„M,   ■■|)i,.    l',„.k,.n.  ■    ,■„„   X„,„...„-.   //■„„,//,.     |!,1    i     ., ,„i 


".Otl 


/  )  /7/rs    //  !  /  /.• 


,iUt-S!l. 


ill  (iiiiiiniii-oii  w  iili  .itli.r  |.:iri-  ,,f  ilir  l..,.|\  in  l\  |.l]ii-  I.  \ ,  r,  in  ■  ..hirii- 
di-tiin  11..11  1.1  -Ml. ill  |".\.  ill  mIii.Ii  iIii  .liai:!.!.  li-ii,-  i:i-|i  ;i|,|,.:i|-.  ,  :nK 
A\\i\    l~   V  I  l'\    al>lllli|:int   'ill   t  li.     |:i<  .  . 

I  III    li  iii|"  laliiiv  in   l»i|li  cli-.ii-r-    it   ill,'  .  ml  ..T   ili,    iniiial    -la^'c   iiip.l 
Ml    iIm     Im -inning    mI'    iIi,.    iin|,ii..ii  .,1     ...nn     iiii|m  ,11  hm  .  .       \\|ii|,     m 

I_v  ||||U-   llif  lr\  t  r  i-    lil^li    iluilli-     llii-     Mini'    allit    111. 1     lai.  1\    (■..iiliniH-    In 
rJM',  then'   ii  alwiiys  a    maik.d    iiH    in    i.  ni|Mi-;ttiii-c    in  \aii..la  ilowii  |. 
aiiij  I  \iii  III  li.u    till    ii.irinal   in  niiiinarv    ra-i -. 

I  111'  ilia-iHi-i-  niav    In    iM  ll-ni-li   ini|M.-.-il.|i    wjun  iji,  t'c    i-   a  mir-l  ion 

l"l^\'in    till     liiliiiinaliii-    In iiliaL'i'-    I'Tiii    .il     l\|ilin-    ti\i|-    an<l    (In- 

aiiali'LI'in-   Imi- t     -liiall-|Mi\ o-iallcij    y/i/,-y, /(/■»/    /,/,/.,/./>«/.        |',.,||i     lr|i- 

n-nil  a  iiilnMnlia;:ir  initial  -Ia-<-  uf  llir  ili-ca-c  ami  mil  lalalK  ImImIi- 
ill)'  ly|iic'al  -\  iii|i|i.in-,  1 -|M  riallv  tlii'  la-li,  1m  ronii  !iil|\  ,|(\  ,|,,|hi|.  |\\cii 
all.  1-  an  aii|.i|i-\  lia-  Im.ii  IuIiI  iI  max  m.l  l^^  |M.--iM,  ),,  airi\c  al  a 
<li  linili'  (omln-ioi  ainl  llir  diaLili'-i-  liiav  lia\(  [n  \<f  i|iii<li<|  l>\  llic 
|iri  \:ilinrc  ..r  ..m  •.]■  llic  ..iImi'  nf  ihr  iw,,  ih-ra-i  -  in  llic  .|i-lri,|  ami 
ill.  |H,--il,ilii\  ,,r  ill,.  |,aii,iii  liasin-  l...,,iii,.  inli.l..l.  Similar  .lilli- 
c  iillii-  ar.  .  ii.'..iinl,  i-i  .1  in  iIh' .lill'.r.  nlial  .liaL^n.'-i-  rimn  -i\.i-i'  lii-ni..r- 
rjiai^i.'  f.irrn-  ..T  ..lli.r  aciilc  iiitiiiinn-  .li-.-a-.-.  I  11.  ..I  r.li  i-  unh  |..  tin- 
i'iinv-|i.inilini;  li.fin-  i>\    -caiit   \\\iv  ami  i\ ,  11  ..I'lv  |ili..i.|  t,\  ,r. 

'I'lic  .lili'.'ivniial  ilia-m-i-  iVi.ni  rclilpsing  fevcf  ilnrliiL'-  tlii^  lir-l, 
.'I'  lAili  till'  -I  r.m.l,  alla.k.  il'tlir  tir-l  lia-  imt  li.-.ii  -ntti.i.iilK  will 
ol)tir\  I'.l,  i-  i\ir.iiirl\  ililliiiilt.  i-iiiiaally  if. mi'  iviii.hilii-r-  ilial  tli.  .li-- 
ca-i'  I't'cn  .•iN'\i-l-  \\  illi  l\  |iliii~  li  \  If,  a-  \\a-  llir  .-a-.'  in  Itirliii  in  1  >^7!i. 
Ill  n....i-,  I'a-.'-  tniiv  i-  m>lliin_  chai-a.'l.  li-lir  ali.iiit  tli.'  niml.'  .if  ..n^j-f 
'.'i~c,  ami  iiltiniair  Inii^lit  ..I  lli.'  Ic\ii-.  Thr  a|i|Maraii.'i'  ami  i^ciuial 
I'liiiilitiiiii  III  til.  [latiriil  :ii'i'  iif  iniK'li  nnH'c  iiii|i.ii'taii.'i'  in  llii'  iliaL''ii<>>is 
'it'  rrla|i-iiii:'  f.'vcr.  A-  a  nil.',  tlir  liciu'I'mI  I'.iii.litinn  i-  ii'inailvalilv  j^ikkI 
111  i'..in|iaii-..n  In  lli.'  li.iL;lit  nl'llii'  f.'\.i'.  llici-.'  i-  litil.'  iiiv  nh  I'ln.nl 
iif  ill.'  ~('ii-.iriiiiii,  ami  tli.-  .mly  -v  ni|il.ii,,  i'iiiii|ilaiMi-<l  nt'  i-  a  iiainfiil 
tiiy;;iiitr  --('ii-ati.in  in  llu'  .'all'  ot'  tli.'  1^J.^  A lllimiiili  tlir^.'  iMiints  ar.' 
in.ir.'  .If  1.'--  in  fa\.ir  nf  rclap-in^-  I'i'M'T.  n.'\-.rth.'l.--  ii  caiiiint  lie  -aid 
tliat  ni.irc  -cv-.tc  initial  -\  iii|it.ini-.  -mli  a-  \i.ilrnl  lii'a.la.lii'  ami  pain  in 
till'  limli-.  w  itii  |ir(i(liiiml  |ir.i-lrili.in  ami  .'Niii  |).'t.'i'liia'  (  I  ni'c.l  ..iiK 
I'.'iniml  till'  r.'a.l.r  ..f  llir  \\ill-kii.i\\  n  ••  llca-liiti'  |-a-li"i,  ali~.iliit.lv 
I'Xrlmlr    ill.'   .'xi-hn.'.'   Ill'  r.'la|i-inL:    l'.'\ir. 

Many  r.la|i-ini.''  I.'mt  |iali.'iit<  |ir.'~i'iil.  at  lli.'  v.tv  li.'trinninLr  "i'  ilic 
ili-.'a-r,  a  |M'.'iiliar  .'.iliir  nl'  lli.'  -kin,  a  |i.iint  that  \\i-  l'r.'.|iifntl\'  ntili/cil 
willi  I'.niMi'kalil.'  -11. '.-I--  ilnrintr  tlii'  i'|ii.li mi.-  in  It.'i'liii,  ami  tli:it  .l.'.iil.'d 
till' a.lniitt;m.'.' ami  a--i;:nim'nt  nf  tlii'  |iatii'iit-  tn  lli.'  vari.ni-  uai'.l-.  It 
i>  a  jR-i'iiiiar,  linll,  yi.'llo\vi>li-j;i';iy  ili>n)liiniiiiin,  wliifli  may  lii'>t  lir  cnin- 


/'/  l'..\'/s/> 


A!»7 


I''""'    I"   ''"     '"I I      HKnilr     IM.IiM.liuU    ulh.     \,:,\r     In,  lit.. I     -..irir    IIIIK- 

I A| I    I.,    ih.     -III1 

^-  i'i::iiil-  t|..  -|.|..ii.  I  ,11111.. I  ;iM|vr  uii|i  until.. I-  uli..  iDiini 
lll.ll  II  |.l.-.lll-  Mll\  .  Il;ll;l.  I.  Il-ll,  .lllalljrlll.lll  ,|l||ili^r  i|„.  j||i||.,|  ,,.|^,. 
..r  iilli.r  (li-.:i-,'. 

'I'll.'  .Il:ii;l|..-I-  ..I'  l.|:i|,-iiiir  j•,.^,.,•_  1,,  .vM.v.r,  .••ill  :il>Mi\-  !„•  , -t:il  ill-li.  .1 
l.y  lllr  lill.lilli;  ,,r  -|,i|||l;,  ill  til,.  |,|,.,m|,  miiiI  ill,-.  ..f-;l|ii.|ll-  AV,  M-ll- 
:il|\    .|.'lli..||-lr;il.|,'  -li..rll_\    ImI,,!,.  ,,r  mI'I.-.-    llirlir-l     >iii,|    ,.\,\\    .;i.-.  •■.■.jin.r 

Mtl.llk. 

I>iinii-  iliiir  -ii!,.,,|ii,iii  ,-.,iii-..    111.'  iw.KJi-,  1-,-  |in-.iiit  -ii.'ii  ni;irk..<I 

«liM.-n  ii.-.-~  thai   ill.-  ili:i::ii..-i-  .anil..!,  lA. .Ill    I.i'\,r\    -piTial    rirniiu- 

-'aii.'.--,   i.iiiaiii   III  .Iciilii    r..r  aii\    l.ii^lli..|    lini.  . 

<  )|     .-..iii-.',    ill.'   <|ia-ii..-i-    iiia>     ,    .-.lit    [iciiliar  .iitliciiltic-    uli.n    a 

" val.-..'iit    IV,, III    r.-Jaji-iiiLT    liA.r    1.    iiiiii„.ii;,i,.l\    attark.-.l    l)\     l\|.|iii, 

(.■\.r.  IMir.ii,.'  Iia-  Im-,ii  iiia.l.'  l..  tin-  .-..iiiiiaiatix .  I\  lr,,,ii,ii|  |„,„i. 
Iiility  (-,■,■  y\,j:,  .-,7,.  Ii  11,,,,,]  lianllx  !„•  ,in|,|i;i.i/,.,l  ili,,!  lli.-  ali-.  ••.•,  ,,t" 
>|.irilla  .liiriii-  ili,-  lM.:iiiiiiiiLr  ..f  lli.'  lix.r,  an. I  ili.  a|.i..'ai-aii.-c  ..f  r.i-,- 
>|H..I-  a   r.u   .la\-  lat.r,  -iitli..'  i,,  i,ii|,,w  ;ni\    .|,,iil,t-  iliat   u\:ty  <\\~i. 

If.la)i-iii-  |i-\.r  lia.l-  n-  natiifally  t..  lli.'  ,|i-,ii-j,,n  ,,f  malarial 
fever.       It    «il|    f,.a.lil\     :,.■   -..,.|i    that    lif-t    atta.-k-    ..f    tlii-   .li-,.a-..    in 

'■ '*'■''•-    "li'-'''    i'-  :i-    "'11    :i-    lyi.liii-.    i-    .liilciiii,'    iiia\     .a-ily    I, ail    t.) 

<':-i-.i|-.  I>illiinlti.-  may  .-|,.viall\  )..■  .■ii...iiiil.r,H|  in  ^v\,-rv  li.rm-  ..f 
malaria  uilli  ,aily  in\  ..|\ .  iii.iit  ,.f  i|i,-  -.•ii-.,riniii  ami  tsvi-M  |ii-..-lrati..ii, 
surli  a-  ......iir  in  tl,..  ir,,|,i..-  :,imI    al-.,    in    I  l..llaml,   1  liiiiuarv ,  ami    Italy. 

A-    ill    icla|i-in^'    C'v.r,  ili,.  ,-\aiiiiiiali f  th,.  |,| 1  ;||;,|  ,1,,.  |in.|in._' .if 

til.'  |.la-m.M|iiini  uill  at  .,mc  .'l.'ar  ii|.  tli,'  .lia-ii..-i-  u  iili,,iit  tl,,.  nrc,'- 
.-ity  ..1' waiting:  l'..r  tli.'  .'Iiarail.  ri-lic  tall  in  t('m|..ratnn'. 

''    '"■'>     '"•    ''^ "liii^Mv     (liUi.'iili,    ,-|„.,'iallv    uli.'ii    a:i    ,'|,i.|.'ini.'    ,,f 

ty|.liiis  fi'vcr    ,'si-t-,   t,,  ,li-tiii-iii-li    i-,,lai.'.l    .a-.-    ,,i'   cryptogenic 

septicopyemia  in  it-  .'aily  -la-..-  tV..m  th.'  initial  ..i-.Tiipliv.'  -ta-c 
•■r  ty|.|iu-  W'vrv.  An  initial  ,'liill  an<l  a  lapi.!  ri-.'  ..f  tlic  t,.mi,,.|-atni'.'  t.. 
a  .'..ii-i.lcraM.'  Ii.i-lit,  early  mark.'.!  iiiv.,lv.'iii,.|it  .if  ii„.  wli.il,'  -\ -t.in, 
os|).'clally  an;'.'liii-  tli..  iltv.-,  ar.'  ,'..mm.,n  I..  Im.iIi  .li-ca-,'-,  ami  tlir 
•  litli.'iilty  may  li.'  finili.i'  iM,'r,.a-,',|,  parti,  iilailv  at  tlir  l.ciriiiiiin^r,  |,y 
the    m...l.' i.f  a|,|„iraii.'.'   aii.l    ili-(ril.iiti..n    ..('  tlic   ciitamH.iH    msli. 

I  ri'c.'iiily  -au  Jill  iiit.'n-iinL'  rw^i'  ..f  tln>  kin. I.  A  viiimtr  man  wli.i  liii.l 
rtM'oiitly  .'..III,-  fn.ni  Sil,....iM  «a- s.'i/.'.j  uiih  vi.il.'iit  .'liills.  licailachc.  ni.'liin- 
an. I  Vdiiiinii'.',  ami  was  a.liiiitt.'.l  t..  mv  .lini.'  uitli  a  l.iirh  fever  ami  marked 
S|i!enie  .'iilar-emeiit,  Tli.r,'  was  'jri'at  ilistiiriiaii.,.  ,if  e.iiisei.iiisiiess.  Tlip 
tever-eiirve  at  tir-l  |,n'>,iii,  ,|  llie  .'haraeter  .if  a  liiirli  c.iiitiim.ius  remittent 
j.'v.'i-.  Iiet«,..'n  tlie  thinl  an. I  f,,iirtli  ,lavs.  afl.'r  a  sli-ht  transit. .rv  iimrliil- 
lit.)rm  rash  .m  the  arms  an. I  thi'jlis  ha. I  ann..M,-,.,l    •,>,  lll.,l,.i;.,..,]    i;,'-;.l    - ii 


i 


;J1»,S 


TV  I'll  IS  I  1:11:1:. 


•MM.Mlhu-   >M>h    MKl.l,.   .1.  ai.|,..;M-MM.V.   uhi,'!,   >„„„    |„.,,,„u     |,W..1,mI    in  rlKua.l.,- 

an.     |.iv>..„i.mI  m  >u.|,ir,„„>   .li>l-ilMitioi,,   I,,!,,,    ,,„„■,.  :,l,u„.|a„.  .n  il„.   i,,,„|. 
^hhI  t,■^l..-|„.■>.•,ll^  ||„.  I,:,,.k,  ,,|-,|„.  t.Tl.MiMl  ninri,  l,.--  ,„,',rk,.,|  .,„  ,  lu    I  ,„l,k 
.\-  a  pncaiil  imiMn    ,M,a-u,v  i!,.|.:,i!,.i,!   «  a>  i>:,lal,  ,|  lo,-,,  i.u   ,lav- 

'''"■^•^""'    ■■'    >'■"    i'"n..n-|,a.,..    -|„„.    a|,|„.an,|    ,„,    ,  h.  .,|,..  „r  ,  1„.    ,,,,,     ,|,r 

pahnar  .,n1a,.>  ,,t  ,u.  tM,.,.r..  ,Ih.  ,aan,ar  M,rla,v,  ,,,-, I,,.  ,,,....  a,,,|  un,|,.,- ,1,,. 
"'■^•.      "V ^'\"'    ''-    ■■'    "".   ,lM.a..   ,1,..    .,.,1,1,,,    a,,|,..ann„v  „,■  a   ! 1. 

li-  ,l,M.n,,>,.  ua.-  ,„„l,n,„.,l  a,  ,l„.  a„t„|,M ,  u  l,i,.l,.  h„u,  .^,.,■.  la, I,.!  |„  .vv.al 


'!"■  'I'lii'-al  1'1,'tMiv  in  a  ix|,i,.al  ra.,.  ,,i- cerebrospinal  menin- 

fi^^t'S   " 'I    -""'    •"    'lil''''-   Hitli,a..„ilv  tV..|„    that    ,,!■  M|,Im,^    trvr    „, 

("■'■'■''"''■■''I  'laiiuvr,,f  , ■,■:•,,.•.  I,nt  ,1  i~  ini,-  i^A-.i-th,!,.--,  ,  hat  irn-nlar 
<-a>i'^,  in  tl„.  ihiiial  Ma,.^^  ,,|  ,1„.  ,„,,  ,|i„,,-,..,  ,,,„,,  ,,,,„,„  ,,,„.i,!,,,,i,i,, 
'''"''■"'"■'-■       ''    '■'"•""    •"•   'I'nl..,!    that    th.av   ^,iv  ,  a-,'-  ,  ,f  ,.,.|,.|„-,,-|,i„al 

'"' .^i'i-'l'^"  l-^in  uitha,.hillan.l.  alt,Ta  r;,|M,|  fi..  „f  „,n,,.fal,nv, 

■■ '    ''■"'    '"    'li~iiiil,: ,.~    ,,f  -,.i,,iiMu--   ,„■   ,.v,.i,    t,,    ,.,,ina.       Ifu,. 

'''■""■'"'"■'•  •''-"   '!"■  ^i"l<''"    li.'.Mla,-h,'  tV uhi.'h  th,'   |,ati,.,it-  Mitr..f.  th( 

pain  in  th,.  ha.'K,  u  hich  ,!,„■-  ,„,t  l.v  anv  in,.an~  aluav-  manih-t  JtMlf 
i'l  '!"'  t^nn  ,.t  a,.hai:i.-l..fi-ti,'  fi-i,lity  ,,|'  ih,.  nc-k.  an,l  th.  .M-raMonal 
ai>|>caf;ni,v  ,,|'  a  r,i-,,,i,iM-  ra~h  ihirin-  the  via'v  lir-t  ,lav>— ,a,i,  |„.fnr,> 
thr  ri-i.lity  ,,f  thr  iKvk— we  liav  >ntli,  i.  i,t  ,  x|,laiiati,,n  i;,r  ,Kva>i,,nal 
(•fi'(,r~  in  <!iM!.''n"-i-. 

Diagnosis  in  the  Stage  of  Eruption.— Kv,,,  alt..-  the  ,.,,,1  ,,f 

iIk'  initial  ~ta-,.  an,l  athT  the  tvphii-  l^vrr  ,-a-|,  has  made  its  appraraiu'c 
aiHllnnnn  t,,  -piva,|.  th,.  .lilllivnlial  .lia-iMisis  may  pn-mt  M„nc  difli- 
I'liltics      'l'li,Tr    ;-  a    lanMiitahlc  want  ,,f  nnai  ■niily  in    tl,,.  ,,|,ini,,i]~   ,,f 

many  phy-i.    in-  anil   iv.^ii    in    tiic   '.u'ltcr   tcxt-l k>    in    ivjrani    t,,   the 

form,  (liMrilmti,,!!,  an,l  (lcvrl,.],i,i,.iit  n\'  tlic  crni.ti.iM.  It  -hmiM  h,.  dis- 
till,'tly  iviii,.ml„.|v,i  tiial  ill,.  >|„.,.iti,.  n ,-,.-- 1 K,t-  arc  aUvav-,  at  ,l,.a>t  in 
X\u-    liciriiminir.    piiivly    hv|,..,,.,ni,-.    ,,rt,.|i    xwy    ,,al,.   an,|    imli-tin,.,.  an,l 

tli.'it  , inly  a  i.,,rti,,ii  ,,t'  iImiii  lat,!-  i„.,.,,m<.  inniv  ,,r  1,.>>  iiiark,.,lly  h,. r- 

Hia-ir.  TIk.iv  i-  a  «i,|,.-|,iva,l  ,.n-,,ii,.,,iw  lM.|i,.|;  and  ,,n,.  that  lia>  I),,!) 
prrpitnat,.,!  in  th,  vi,.i,,M-  nam,.  ,,f  ••  y,< /,,•/,;„/  t./.h^s."  that  th,.  ,.nipti,,n 
'.f  tvphii-  t;.v,.r  rnini  th,.  v,.|-v  ,,iit-,.|  tak,.~  th,.  torm  ,.f  -mal!  ;,.„„„- 
rhai:,.-.      On    th,.   cmtrarv.    ii    may  1,,.   -tat,.,l    ,l,.tinit,.lv  that    anv  IMiril,. 

'"'"'■    '"    "'''■■''    ''"■  '■'"•" -   rhaii^r,.-    a*    ,,n,'..  app,.ar   in    th,     liinn    ,,f 

lar-.r  ,.r  -niallcr  h,.m,,rrlia-,.-.  with,,iil  any  pnidiv-inal  Man,.,  i-  ii,it 
typliii-   )i.\,|.. 

Diagnostic  Significance  of  the  Eruption.-An.ith.r  p„i„t 


l>/.ll,\liSlS. 


599 


1,'ciicI'mI    iiii|Mii'ian''c   iiia\'  I 


ic    n]rrilii.nr( 


I.       It    i>    ll 


K'   iircnl  \ari:il>ilii\ 


lit     the    rTlintmu    a-     IV;.ia|-iU     it- 


ilpiiiiilaiK  1'  ami    iji-iriliiiii 


i.iiv  ra-c-  uiii,  aiiiiiMiaiit    rni|.tioi v.riii-    tlir  ti-iink   aii<l   rxliviiiili.v. 

ur  liavi'  i'\,rv  |Mj-il)l,.  -i-ailalion,  ,l,,\ui  lo  ih,,-,.  .a-,.-.  in  uliirli,  t 
very  hc-iiiiiiii-iiftlic  di-ca-c  ami  llin.ii-lhiiit  it- ciiiiiv  diiial 


IlllJI  Ilic 


ticall 


y  ii]]|Mi— .il)lc  til  (IciiiDii-lratr  aiiv  iliufactrii-tic  cliai 


K\cii  ca-o  ot' -ii-callc(l  "  l'</,,is  '.iiiiilliniKit 


ilii'ii,  ll  I-  |ii-ac- 
ii;i-  ill  the  -kin. 


rai'i'.  caiimit 


lie   liitiiTlv   (Aclm 


It 


/'•((  siiii   ' ,ni iilli,  iiifili  "  altl 


1-   civwn^-   til   till-    want   <<(  ii 


i"iii;li 


liiriiiily  ill    llir  fni|itioii.  Ii.itli    a-   iv-anU    it-   ^riin-al  a|.|icafamT  di 
riiiir-   and  alMi  in  imiividiial    |iati(iit>  diiriiiu-  tlic  siiiir 


ilill'n-ciit  ciiid 


lii'.    that    tlic    d 


lii^iiiisis    ti-diii    (itliir    iiil'crtiiiii- 


ili-ca-c-   cliiiractiri/c* 


iiv  liii^h    Icvir  w 


itlmul,  111-  at  lii-t   with  vcrv  -lii;lit,  cli 


iii^ir-   ill  the   -ki 


lliav  lie  cNrivdiiiylv  dilliciilt. 


Ditliiplt 


ic-    lit'  tlii-    kind    iirc-ciil    thiiii-i>|vc<    i'-|ic.'iallv    when    it    is 


iiciM'--ai'\     to   (Ici'ii 


it\Mvii    typhii-    a:    I     ty|ili<iid     C 


\i  I',    lh(     di-ca>o 


whirh,  111  all    It-   -ta^c-   ami    in   all    ll 
rclatiii 


itiii'i'-,  -tJinds  in  cld-r-i 


ii-lii|>ti.  it  ami  which  iindniil.tcdly  |iiv-ciii,-  the  uivatcst  dill 


iliaiiiiiislic 


ill  ditl'crciitial  dia^rn 


ICIlItU" 


I  ISIS 


Typhus  and  Typhoid  Roseolse.  -1 


cru|itiiiii,   which    is  so  ut'tc 
ll 


n  fcLTiird    til   the   rnsciiliii 


11    considered    iliai,aiiistic,    it    iiiav    I 


•e     eiiilallV 


uliiimlaiit    ill-    eijiially    scanty    in    liutli    di-euses.       It 


lillted    nut    that    cases  nt"  ty|»lius    fever,   I 
';,'imiiiiir,  may  present  milv  a  t 


lias   ali'caih- 


ii>we\er   -evere   t'riini  the  v( 


ew  n.-eiihe  scattere-l  exactly  as  in  tv|(iii.i(l 
fever,  and.  conversely.  ty|ili,iid  ('ever  may  he  .•oinliimKJ  witli  a  rash  tliat 
even  in  ty|ilius  fever  wmiM  have  to  he  re-:ird(KJ  as  ahnmlant.  Sj,,,.,., 
then,  tlu    niiinherof  the   rose-i.ots   cannot    he   depended  upon,  it  is  all 


th"  more  niipi.rtaiit  to  make  a  careful  study  of  their  iikhK.  of  devel- 
iipment,  di>triliiitic.n,  and  individual  clianicteristiis.  1,,  repird  f..  tlio 
ilevelopiiieiit.it  is  to  he  imt.Hl  that  the  rash  of  typhus  fever  appears 
Mch    carli.'r    than    that    of    typhoid    f;.ver— lielwirn    the    scvoiid 


vi'iv    ni 


(1  (ifth  (lavs  of  till 


lisease — that    the   1 


unhroken  succ<ssiiin  in-tead  of  ii 


esion-   ciiiiliiilie   to   a 


male  nnmher  and  developiiieiit   within  a  few  da 


-I essive  cnijis,  and  reach  tin 


ppi 


The  distiihntinii  nt'  tli 


se-spots  over   the   surface  of  the   hodv 


next  m  im|)nrtanee.  Whereas  in  typlmid  fever  llie  trunk  is  mosttliicklv 
covered  and  the  extreinities  e-cape  altoirether.  or  the  s|«,ts  Ixvonie  less 
ind  less  uuinen.ns  the  jrreater  the  distance  of  the  part-   fmiii  the  trunk 


tl 


and  the  extremiti 


I'l-uptiim  in  typliii-  fe\ci     -  tairlv  iiiiifnrm  and 


ivers  hoth  the  triink 


I{i,M'-sp,it>  on  the  iWrcarins  and  Icl^s  and  mi  the  hands  and   ( 


;\\ti'eiiieiy  rare  in  Ivplmid 


ect   are 


ever,   wliere; 


i>   iiivoivcinent   of  the  hacks  of 


^1 


l;i 


<;iiii 


rv  I'll  IS  Fi:\i:i:. 

''"■  ''•""'-   ■""'    '•'•'    i-   '^f'viucly  mil,,,,.  „nt  to  <;,v  Iv,,lr,n,  i„  lv|,lii,, 

Irv.T.   .,  ,|,:it    I    ;i|u;.v-    -lll.i..,.t  llir-r   (ilarr-    „ ,  a  c.in'tlli    .A; „ali,,„    i,i 

aiiv   -ii~|iiii.iii-  ca-r. 

.\ltli,m:.|,tl„.  a|,|.r,,vin< Iil,r  ta,v  in  tl„- lu,,  ,|i.,        .  j,  ,,.  .,  ,,,,,,,,,,„ 

.■Mr„l  H„,ilai-   i„    -,,    la,-   a-    i,    „rv,  ,■   l„. .,   ,|,,    -,  , ,  ,,)    n.M-|M,i~  in 

lv|,li,,i,l,  a.i.l  v.rv  rai-ly  i„  ,v|,|,i,-   i;.v,i-,  y,  ;   ,l„.iv  i-  a  ,iiai-k...l  .■.iniraM 
""•'"—1    thr    IM,rli~,  iv   -uull.,,.    r,..l,|,.li,.,|     ti„ir~.    will,   .l,v|,|v    liij,.,,,.,!    or 
.vni    li,.,iio,Tl,a^i,.  .■u„ji„i..,iva.  aiMl  uil,|  |,„,k  ,,f  a  tv,,liii>  CrNvr  ,,ali,.„t 
=""'  ''"•  l'^'"''''  -"i|""'"ii-.  ^"1,1  |,p,Mral,,|  a|,|M.aiMii,v  in  ,x|,|„,M  ,;,,,,■. 

n.-  ii.iivi,li,al  l,.~i,,„-  |,n-,,it  v.rv  ,.,„,H.|,.,-al,l,.a,i,i.liMi„r,  .litHr- 
on,r~  m  ,li,.  ,u„  .li.,,,-...  Wl,,,,,,,.  ,|ir  ,■„.,-.,„„.  nf  ,v|,li„i,l  |;.v,t 
•"■'■    <i''"n    tin     K.^\nu\u's    clcvat-.l.    |.a|,i,la,-,    uitli    -lia,-|,,    riiyiilai-    ,,iit- 

Inir^.  an,!    ivtai,,  tIm  ir  ,,i,ivlv  liy|„T,iiKr  ••hara,  t,r  tlii-Mii^li,,,,,.  t n,,,- 

"""  "'■  '.M'l'"-  f'vrr  at  tii-l  a,,,M.aiv  i,,  ,|„.  t;.n„  ,,r  ,,ai,,  i,M|iMinrl 
l:yi..Tr.,„„-  |,al,-!u-.  ui-|,  Inv.^ular.  iil-,1,  li,„.l  Imnlr,-.  w  hirli  >jn,.li,ally 
l"'''"nic  .larkiT  aii'l  .•vnitually  >,„i„.\vliat  lirniniTliaiiic  ((•o,ii|)ar('"^l'latos  1 
'","'  -'•  "'"'■'■  "I"'  'i-ii-|.a|mlar  .■liaivinrr  ,,f  thr  ,  n,|„i,,ii  ,i,„-in)r  .,n.l 
Jitl.Ttlic  lici-lit  of  i,.  ,|,A..ln,„iH,i,  i-  an  i„,|Mrlain  <lia,u,i"-ti,'  ti-atniv. 
Tho  sput-  arc  pal,-.  ,-m,|  ,,„lv  ,|ii,-i„^  ,]„■  ti,--,  H.„  li,„i,--.  a,-,-  lli,.v  slii.riitly 
,.l,.\al.-,|_ii,.v,-i-  -,,  ,liMiii,-il\    papilla,- a>  i,i  ty|.|i,,i,|  i;.v,.r. 

OTHER   DIFFERENTIAL  SIGNS    BETWEEN  TYPHUS  AND  TYPHOID. 

.Sv.,M,|j„ily  ii,  ini|M,rt,in,-,.  t,,  ih,.  ,.,,n,ii,i,„,  ,,('  ,1,,,  .|,i„  j,  ,|„,  ,-,.^.^,^ 
Ill  III,'  ,litr,-,-,-nlial  <liauii,,-i-  li,-iu,-,n  tli,-  tu,,  .iiMa-,.-.  I,,  .•,,i,ti-a,livtin(- 
tii.n  t.,  III,.  >],,\v,  M,-p-]ik,.  a>,-,-rii  ,,r  tli,.  ,-n,-v,-  inl\pli,,i,|  t;.v,T.  nv,.  hav,. 
>.■<■„  that  in  tvpliiis  i;.v,T.  att.T  an  initial  .liill.  th,-  I.-inp,T;it,i,-,.  ,api,liy— 

witiiin    ti-,,n,    lw,.,iiy-t;„„-t,,  tnrty-,  idit    li,,„i- an<lwitli   nM„-li   M,iall,T 

nini-nin-  ,-,„,i~M,,iw.  i-i„.,  ,.,  a  l„a^l„  ,-a,-,.ly  ,-,,„.|„.,|  in  ,|„,  |;,,„„.,-  ,lis- 
•"'-'■•  T,n,p,-,-;,n,r,-^  ,,r  t(i..-i  C.  ,„■  ,-v,.n  II  .-ir,-.  a~  u.-  Iiav,.  >,...„.  .piit,. 
••"Hiiii"ii  .-It  tlii-  Ma-,-.  an,l  may  p, a-.i-t  a,„l  ,-v,„  .-..ntini,,.  t,,  iii,.,-,,,H- 
with  r,-!ativ,-ly  -lidit  m.M-.iiiii.-  n-mi-i.m^  mit:!  tli,-  ,-n,|  ,,ftli,'  tii--I  ^^^^vk. 
'V\\v  .-hai-a,-!,-!-  ,,f  ti„.  t,-nip,.i-,-ii,„-,-rin-v,-  ,li,,-iiio  tl,;.  (j,.,,  „-,,,,|^  p,,.itiv,.lv 
.li-tiiiL-iii-lii-.  lypliii.  Cn^n  iypli,,i,|  t,.v,a-.  A-  .■v,-n  tli,-  ni,,.t  -,v,t,-  ..as-.s 
•.ftypim-  i;.v,T  ,-a,-,-lv  laM  in.,,-,-  ilian  tV,,,,,  i;„„-„,,,,  ,, ,  .,.v.-ni,-,,,.  ,„- at  m„M 
lU'-nty.  -lay-  i„-t;„-,-  ,l,-t;i-v,-,-,  ii,-,.  1„  ,rin..  an,!  th,-  i--v,-i-  iiill.  |,v  ,-,i.i~  ,„■ 
■■It  l,a~t  l,y  a  Mi,-,-,.-i.,n  ,,f  lapi,!  ,l..,-li,„..,  „,.  a,-,.  n,.t  «ill„„it  i,„p,,|-iant 
<liH('r,-iilial  .-i-ii~,  ,.v,-ii  -iiii-in-  tli,-  latt,-,-  p,-,-i,„i  ,.,    ,1,,.  ,|iM.a-,-. 

Ill  a,-.-,,i-,ian,-,-  uitli  il,,.  i-api,|  n„.  an,!  :;i-,at  i,,t,n-it\  ,,|-  tin-  ll-v,.,- 
<liii-iii.L-  til,-  Cf-I  .lay-  ,,r  til,-  ,li>,-a-,-tli,-  ,!i-tiii-lKiiH-,-  ,,r  tl,,-' i,ati,-,!t'-.  .,,,- 
'>ral  ,-on,iiti,„,  an-  „„„-li  „„„•,■  m-v,  ,-,-  ami  manill-M  tli,ii,>,.|v,.s  niiicl,  .-arli.-r 
tiian  in  typln.i,!  fcv,-!-. 


/'/.  l'..VO.S7,s-. 


(;()i 


^\' 


ifi'cas   ,1    i\|il 


ir  al  \i':\-\  (|. 


I'aliciii    not    iiit'iV(|iiHiill_v  iTiiiaiii-   at    \v,.rk 


'I'-   not   MO  t,,  1„.,|  diiriiiL'  tln'   tir-t  \\,rk   ..!'  i| 


jn-o.-lratioii    ill    is],|iii,    j,    ..,,  j,|.,.;ii    Cniiii    tli 
Jtatii'iit-^  ari'  foiTtd  lu  take  tn  their  IkmI- 


'I-   (li-ia-c.  the 
if,L:iniiiiiir    that    the 


I) 


111  the  lii-t    or    t 


IC     --fCOIKl     il,|\ 


'■'"'"""■   -ll'l""-.  ^111.1    a  .Irriarc  ihrni-rlv.-    (hirili-  tllf  tir-l    Urck 


ICC   I-   iiila\((l   mil 


t.vphii-;  i'cwr.  Iiiit  their  a|i|icarai 

or.  it'  they  <lo  e.\ce|itioiiaily  oceiir  earlv,  tliev  are  il 

eom|ilii-atioii. 


ell     lollet 


1'  ill  typhoid, 


lie    to    -oiiie    eerelir; 


M  iiiaiiN'  rc' 


■I-   tile    |Mll-e   ill    |y|,||i|,    .JiHir-    eo||.i,|erah 


■|ihol(i  (ever.       '|"he  rekitivel 


V  low  rate 


usually  ol)~ervei| 

of  the  latter  di-ca-e  in  yoiitlitiil   iii<li\iili 

is  not  ol)~ervc.l  in  typhis  ('.■v.'r.       In  hotli  -exe>  and  in  ail 

is   i'<>ni|)arativciy  ra|iid  from  liic  ver\    iiejri 


>    I'roni   tiiat 
eliaraeteri-tic 


-|ieeially  ot'  tile  iiuih 


tlie  |illl~i 


■iiin^r    ,<    not    imii-nal    even    dnriiiu'-    th. 


T 


fll-l     Wrik 


ami    mole  in  liic 
in    \i;i'oroii»    men. 


IC    cliaracle;-i~tie     iheroti^m 


i~er\ed    in   typhii-    t'ever. 


ill     tynjioid     iv     uiil 


\      e.\e< 


juioiiaily 


K 


niarureiiieiit  ot'  th 


lypiioid  tliaii  in  t\  |)liii~  ti'scr.      '| 


c  -|iieeii  is  a  more  reMiilar  ami  la-tinjr  | 


in  ilie  two  <h',- 


he  tune  ot  It-  a|i|iear;in 


In  t 


yiihii-   tevir,  if  it 


PI" 
i-    lifc-ent  at 


early  ami  di-a|i|iear~  at  a  time  u  hen  it 


>lieiioniciioti 

iilso  dilVers 

it  a|i|iears 


would    -111 


tevcr. 


'c  present  in  t\  plioid 


Till 


sln;ii^ 


'>nini:i!  -ymptoiii- are  ..f  very  little  im|tortai 


Ix'twocn  the  iwo  di>ca-cs.       j"! 


lee  a>  (|iai:ilo>tli 


iplite   eomnioniy  deve|o| 


Ills  a  moderate  (leer,.,,  ,,(' 


iiicicorisiii 


li:nid,  il    may  lie  ahsent    diiriii;:  tj 
attack    and    n-naliy  i-  .-o  diiriiii:   the   eirlv  >ta 
tiny  mean-  ^o   eon-taiit    in   ty|ilioid   fe\-er  as   i 
in  typhus   thin   -tools  of  a    pale  ycll-w  c.ilor 


)S  111  ,-cvclv     'M-e-  of  typhll-.  while,  on  the  oti 


ler 


IC  .  iitirc   diinition    of  a    tyjihoiM    tl'V 


cr 

Diarrhea'  i-  uot    hv 


Sonic  of  the  newer  methods  of 


>    n-nally  -ii])|Ki-ed.  wliih 
iii'c   not  at  all  nncomiiioii 


tl 


iiimatioii  will,  ,„,  doiilit,  p 


ic  jlivalcst  value  in  future  ciiMemie-    and  will  help  to  .leeide  the'd 


iiosi-  111  niaiiv  a  doiihtfnl 


Th 


•li'iiKin-tnilii,!!  ,,f  iyp||,,i,|   |,:i,.i||i  i,,  ,1„.  i,i,„„i_ 


and   h'ce-,  and  the  lu'liavior  of  enlimv^  ,,f  thi-   1 


the    hlood--i'rnni    of    tin-    indixii 
method-. 

'rheCrnl.cr-Wid.il  ; 1 


liial 


linile,   rose-spots, 
ia<illiis  when  ;idded  to 


are   the   ino-t    imixirtant   of   tl 


(litl'creiitiate   tl 
later  stairi 


.L:;i:hltni:itii>n  te-t   will  eiiahle  lis  i 


IC   twii  di-ea-e-,  altlioiiirh.  i 


tllesc 


II  inanv  cases  to 


1    i~   true,  oiilv  .-It 


a    soMiewlial 


Wh.ti 


ler  the   ah-eii 


ce   o|     lellkoi'V  to-i-    or    In 


111  typhoid  fever  will  di<tiii-ui-l 

'  CoinjKin-  till'  cliiiptiT  ..n  ilii-  -ill 


ileiik 


•\(o-i-   oil 


1  tin-  from  typhus,  as  it  does  from  ,-ome 
i'Tl  in  till'  Miitlier-  work  m,  ty)ili.ii,i  tVvcr. 


i       1' 


r: 


i*??f 

m 


fiOL* 


/■)77//-.s  ii:vi  n. 


li! 


';'■""""';■'•;"■'"•■  '"'•■■••i 'li-— M..|    ..-  ,,n,.Mmo„ia  a,HU..,.ti, - 

;'""■"-"'"'■''•'-    "'■•■'"    l^nnu,,,.i:,.h,rlv     i,„u   a  MMi-k,..!    1,.  I.,,..,,.!, 

""■'■"^'-•'  '""'        ■'"'"■'■  "'■"l,i„.  hi l-,.,.lNi,Ml,..  1,1 l„r,v|,|,„-i;.v..r 

T""";-      '■'""■  ^'""^   '■'■'•'■'"'^   "■•-^'"■''  i"  'I'"  •'"l'-'~    no|,ki„~    H,„,,i,,l 

.-li"Ur(|    ;i    inn,|,.r:ii,.    ,i,.jr|v,.    ,,|'   l.nk,  „vl,  ,>i.. 

,''"'"■  '"^"^"-'■'•^"'i ^  |Hol,;,l,U    „„,of;n,v  .liauM,„,i,.  valMP.      S.vrnl 

"""'"!'••"• -'•   Virrnnli-hav,.   In  .,,„.n,ly  . ;„„,.!  i,  „,  ho  ,,„.;,;,,.  j,, 

t\  [ihii~  t(\cr.  .  ' 

Whil..    ,hc.   .litfLivntial    ,|ia.M,M-~    (V,„n   Hnall-|„,x.  n-    ^^o    havo   ..,, 
I'lv-oMN  o,,,,t  .htlinihi,..,  .  .,„...iai|v  .Inrin.  ,l„.   initial  >,a..  .  ,„|„.r  umw 
.■XM„tl„.,„at;,,  ,.arti,.Mlarly  „„a-l,.„  may.  ,lnm,^   ,1„.   ,,c.,-i„.|  „C  .,.„,„i„„ 
I"--'  'M'^'llr  .-MtMMM..     TIh.  ,.n,,.,i„n  of  measles,  .......iallv  ,I,„W 


tlir   lirM    i;.u    li,,iir-   afli 


iiijr 


!y|>liii>    tcvri-.    ami,    <m,ii vci-^dv,    tli,'    r; 


'•  "     .■i|i|,(aranc...  may  v\n^,-\y  n-rmhl,.   that   of 


h,.. 


.      .  i-ii    iif   ty|)l]ii-   t;.vrr    h.ihn.    the 

.mnm^    ,,t     l,..„„n-!,ai,i,.    tivni-lhnnatinn,    uh,,,    i,    is   ahnn,la.,t    a,,.! 
-•""""•■'"    M.    plar,.,    ami    a,vnm,,ani...l    hy   tl,.    ma.ailar    ra-h   ,|,..t    In. 
'""■';  '''■^•■'■''"■'''  '"^'.v  "■•'-iiy  h-  ,-„„i;,Mml..,|  with  tho  t.n.ptiun  of  „K.a.|'. 
A~  a  n.l.,  ,l„.  ,|,a;:,„M,  .,„,  h,.  ma,l..  hy  a  ,.a,vf),l  ,.xa>ninati.,n  of  the 
-v.na.,,,    M-ofth,.  .kin.       It    i.    t,.  h.   ,vn„.n,h,.n.|    ,l,a,    ,]„,  f,,„    j,    H,.t 
n.ta.k,.l    n,    ,,u.a>l,.-,  whil..    in    typla,.    ,;.v,.r   it    ,..,.,„.   ..ntitvlv,  or    i„ 
n..v   ..as..,    ,s     ho    ..at    of   a    h.w    i,olat...l    rose->,.o,s    whi,.h    \u.n   are 
<•  Mnmt..n-t„..       In   any   ..a>..  of   ,y,,hn,   fW.,,-,   ^v,.,.   wh..,,    tl„.   ra-h   is 
='l;"-'<l^-,t.  an.a.  w„l  l„.  f„„ml  on  th..  l.o.|y  wh,.,v  it  i.  n.or..  spa.-M.lv  .lis' 
tnhnt.Kl   an.l  wh.,-.  ,h,.  .,„.ts  atv  .listin..,   ..moukI.  „,  nutk.  tlu.n,   i.a-ilv 
rccoanizaiilc.  ■^ 

Th,.  conv,.rsio„  of  at  least  a  pan  of  th.^  n,s,.-s,v,ts  i„t.,  pH...hia. 
IS  ..t  soin,.  .lup.osti..  vain,,  fhr  typhns  f,.v,.r.  H,.n,o,ThaKi,.  ,n,.a.h.s  is 
n....  an,l  n..,.,l  hanlly  1„.  tak-n  into  ,.onsi,|,.n,tio„  i„  ,]„,  ,|i„i,,,,„ti,, 
(iia^rm^is. 

Th,.  ,.on,li,ion  of  ,|„.  n,n,.ons  m,.,nl.ra„,.s  (,.f,nj„n,.tiva..  t.asopha.-vnx 
l.rom.ln,  pr,.-.,„~  nothing  .listitrntiv...  Catarrh  of  thos,.  s„,,..u.r,.s 
o....n,>  m  hoth  ,li..a.,.~.  an.l  ,h..  in,..nsity  ami  ,list,.il,ntion  atv  so 
vnnaM..  that    it    ,s   inipo^-ihl,.  to  ,lr,,w   anv   ,|..|init,.  .-omhwion 

It   th..  pati.nt-  ar,.  .vn  .Inrin,,  ,h,.  |„..innin,r  of  ,h,,  <;,,,.,  |,,,;,,^.  „,p 

'■;■"'""";  ='l'l"="-^-   '"•   '•'  '•-'!=''''"  <l^"^'    i"    ■•..^anl   t,.   this   p,.ri „,   h^ 

"l>ta,M,.l.    th..    ,l,.,.ision    lH.,.o,m.s    mn,.h    ,.asi..r.        Th..    rapi.l    ri..    .,„,! 

""Nsnal    h..,;:ht   of  th..   t..mp,.ratnr,.,  an.l    it.    p,.r..is„.n, r  ..v,.n    m.I.s,. 

<l'-nt    n-,.  a(t,.r  th,.  app,.a,.„i,.,.  of  th,.  ornption   an,l   ,lnrinir  th,.  ..ntir,. 
tn-st    w,.,k   ot    ih,.  ,lts,.as,.,   ar..   iK.vcr  ,.l,s,.rv,.,|   in    ni<.asl,.s. 

<  .th.r  ,liM.,.,..  that   an.  .K.«,sionally  n„.ntion„l  i„  this  c^mne,.tio„  aro 


I>/.\(,.\nsis. 


603 


'4  -.cnlKlurv  illl|H,lt;itlcc  ill  ill.,  (litrclviili.il  ,  I  i:iir,|,  ,-i,.  |  „  x,.|v  r:ir.. 
c:iM-  :i  rciiiml  pneumonia  Iumn  1,,c,,iii,.  a  ^uiinv  ,,t'  irnii'.  l-.v,ii 
iiKMV    rmvlv,  and    (Hilv    iindrr    -|ircial    .  ,,n(liti.,ii-.,  an    .Tr,,r   ini-lii    orciir 

in  scarlatina,  certain  infectious  exanthemata,  and  i,;  -rvdv 
ciiMs  ol  purpura. 

Anthrax  and  |Mi->il,lv  glanders  mi-ln  \>>\-  a  limc  -ivc  li-,.  u> 

duiilil,  the  llirniiT  only  in  tlir  r\liviii,.|y  raiv  ra-i- ol' civlirai  or  inl.-tinal 
antlirax  uiili,,iit    rd.ina  or  fiinin.Mil.KJ- ;   the  iatirr,  wiim  tii.' ciiaracl.T- 

i-tic    inaiiill.-.tati..ii~  in    il,,.  , .,,i|,    ni<.|iiln-anc  of  tlic  ii,,~,.,  tin, .lira,  and 

'"•oiirlii  air  I,-,  marked  :in<l  tli..  .lianurs  in  the  -kin  aiv  iin|«  itivilv 
(level,, |)..d.  In  the  ea>e  ,,f  anilii-nx  tii,.  ,|ii,.>tion  xv,,iil,l  |„.  ,|,.,.i,|,,|  ;,'t 
on,,.  I.y  th,.  l.a<-t.ri,,|,,irie  exainiiiation,  wliieli  in  jrhuideiv  i>  often  more 
ditlieiilt. 


i-''!*' 


PROPHYLAXIS. 


,     ■'•■'■'■""■"-'--  --•'^"„wl..,l:„.,„-,|...,M„MVan,In,„.|,.„r 

'':''"':'^~"'""':''">'--'^'"'""' 'i^i.,  .n.u,„va,i  ,„■ , ,i.,,.,.: 

•"'•:"""■"■;"':"'"' "■""•■'- '-    '■■-l„,„    ..,,.„i„   .|,,ini„.   ,„...- 

'■"'" :    "'"'■''   ■'"'■   ''■'■>    "'li'-i'-n.,  if  ,,r„,..Hy    .,.m,.,l   .„,.,  ....i,,,,    ,|„. 

.nn,M,,.H„M    ,„•  ,|„.    Wi..:,..    ,n„n     ...i,.,..    ...    ,..,i,..„    ,„,,    ;„      ,.„„,.^.| 
■-liii'iiil.  *" 

''"'"■   ■""-'    nn|,u,-,:,„t    ,.„iM,-    in    ,1„.   ,„vv,.„,i„„   „,■  , ,i.,,^,,„   ,,.,^.„ 

l>.-^    r,nl„„iu..l    iu    a    i;.„    ..,M,..|UM„„.   at    .Ik...,.,!    „r   ,|,.,    ..l,,,,,,.,. '  „„ 


REGULATION  OF  GENERAL   AND  LOCAL   HYGIENIC  CONDITIONS 

.""■    l'-'-"-na.v  „„.:,.„•..,    I,a..,|  „„    ,1„... .,|,.,.a,i„„>    n,av  1„. 

'"'";''■;'    """"'"'-'■   ''-•■'•>    iM,,.n,vin^    ,l„.   ,,.,,..,,,1   an,|    l,,,,.!    l,v,..i,.ni.. 
-''■I't-M.  ,|,..o-iv,.  ,1..  Wi..a..  ur  a  |,n,|.,  ,.  n,,..lium  ti,r  i,.  ,|..v.i.,;,,,,,, 

"""'""""""■  ^":'''-'"-  "-'"■>•  ''-"-"1-M''r ~.nr,l„.,,,,.,a.|,V,„n 

,         '["■'  !''    ''';■  ' '    ""l""-'^""    l"-'rl-  l^"'ti-  pnn..i|,l...  u,.v  liis,    lai,| 

""';•'  ''''-""I"-.  -n„n.  u , .■ha...x,.n.s..l,|,..,„„„„,, 

;"'■';•""'    '"""■  "'.■,niv,„.ally  ,l,:,n    IliM,. ,,,,,1.       !!,„    ,,-,.„    I,.,    lik. 

'"■'  " /'•';" ''■''■"'"^'■'••^^- '"-<■'• '|m..'.l.l...,.,i,ll,i,nM.|r„r,l,„ 

'''■■^^  'I-'  ll-  'i'-M..  n,i,l„  ari..  >p,„,am.uu>ly.  a  .h,.,,,.-  ,|,a,  ,„-,lav  I,.,. 
'>i  rii  |M  I'liiaiii  nil\-  icliilrd.  '  •       " 

'';'"'■;"■''•  '"  "'>-'-  - '■  ^'"fl""-  I'av.  .l.,n,.,ll,al  anvthi,,^  ,l,at  .I,,.-. 

:-';''-'-'lv::ti;..,h,.,l,.v,.|„,.n,..n,a,„U,,n.a.l„C,|„.-,;....i,i... ,,,;,„„ 

'^:     .'";   '"."'-7"""''  """'•'  I- '—v,.rl„„l<,l„.n„M    important  ovM.Tal 

'"■.""■'l'''.-'"!'"'!""^'"'' <•  'I-  .li-n...       \V,.k„„u„,a.  In„„„.,.an.l 

"";"■;■'""'""■""'    '=""'•  "V..,vn,w,|i„.i„|,a.llvv,.n,ila...,l    r ,-    ,il,|, 

7""'';""'""""''^'""""'''' '"I-'-iM;:M,lMaM,....,.a,„M„.  i,  i,,,.,,.'    ,„■„' 

'"■".''"■'■"""'^■"""■'■'.M'l'"^    f.  v..,-.  I„i,  u..   a,v  ,v    lullv,l,an    ..,■,• 

;';"""'7'    "''"    "''-afK.nl  a  „.„-,    ,;.v,„.al,1 11    il,,-    i,.   .i;.v,.|„,,n„.„. 

':'";:""'    "-;';••'-...-•  ,v,,l,n-;    l,.. ,l„..ii.tin.,lv.„.ial    natun.uf 

•in-  .1,-,:,...  ul„-l,  aua.k-  ,1..  ,„.livi.|„al   ulu.,K.v.r  l.is  lu.dti,  luw  l,...„ 


ri;'irii    ■  i.v/.v. 


Illli|('i'lllillr<l     I 
till'    Icrcjil  li  11 


l\     IlimU'lT    MIJ<i    vi 


<l     III-     Im»|v   I 


Tl,r     .1 


i'll"ll     :lllil     llc\rlM|i|lli-|||     .,f    tllr     -I 


»j<)6 


'■■i~    Imiii    |iiv|(miv(|    tlir 


i"ll(~l    \\:i\    {'•']■  llii>  -t;itc  :ii|(| 


ll-r  i-c  ul'   it- 


'll    I-     In    llll|pni\,'     tlic    Uill- 


"■iily   ill  -en, nil    lo  .1,  |,ii 


\i'  rill 


•f    lllr    Ir-      Ihvnivil    ,|; 


"iliM    ^111(1  -Miiitai 


\    l''lll(llll(pll.. 


till  IV  i-  (Liii-cr  iif  ill,.  ,|i. 


l--(-,    l-|lfi-|;lll\    111    IT^iMii- 


:iiii|  (liiniijr  liiiM-  vvli, 


III    1: 


i';l-c-|l(il-ii|l    lirlll^     llll|l(>l't( 


ir^V     I'lllr-, 


-|"riall\     .lllnili:     llllll-     nt' 


.r     ll 


•|ili|rrill",    ||||.    t,.| 


I ■'■!■   li"l'iilaliiiii.    the    I ivr    iiiii-    mikI    .■Ii,m|>    1 


irninit- 


(miiiu  II   ih   lirrliii  a-  "  r 


|>     liiilulllii- l-l-~ 


I.v  tl 


iiiicii     I,  all  iii-Diiilioii-  ii.r   ili(„,.  xvl 

'III  II 


''"""■^-  "'"'l^l -'-•  I rlMm-..-,an.l  |.ri-un-  -Im,iiI,|  I 


Ki   llU\r  111 


u-   aiitlionii, 


All 


-iiliiiTtcj    t..   a    raivl'iil 


"■  raivliilly  iii-|Hct,.(| 
-|"'.aallv  niiiuraiit   -liii.-.  -JiuiiM  :,1„,  1,,. 


w 


lll-|)rctl(.!i. 


■in--  wa-vd  III  a  coiintrv  in  wLid,  ih,.  ,lj. 


-mualily  i'|iii|iiiiic.  || 
'ii>iiii.'-   i.f  iii|.   In 


I'a-c    i~    |)i(.- 


Ih 


L;nat(-t    attiiiticii    -li,,ii|i|    | 


!<•  i^ui'ii   to  a    |ii<i|H'r 


r-,  tlir   arf;i.iu,niriii    ,,f  tli<'   ca,,,!,,  and    the    ti,.|iri; 


ll    L'-fiicral    caiv   d'  th,.   -..Mirr-'  Ixm! 


Hiiw  niiH'h  can  I 


llir  ( 


"■;i'-<'"iii|ili-lir.l  in  tlii-  (liivctidii  ua-   >li,,«n   .liiWnu; 


'lir  (  nniraii  war,  in   |S.-,<;,  ...,„.,.iall.v  .Inrin;^  ,1,,.  >i,.u,.  ,,f  .S.|,a. „|.  | 


till'  ilitl'dviit 


>iiiliiiiin-  i.t'tlir  Ki'dii'li  and  Kmrji 


iiiiiililcr  tl,  -lii.iildir. 


\VI 


IXiMt  artnii-,  wliirji  tl,iii,'lit 


ii'iii^'-  till'  Kn<;li-li.  will,-,'  1 


ii'l-ca-  till'  iliM'a.-r   i-ai-fii'd  nil'  liut  t 


<'\v  virtmis 


raliiinally  (I'd,  tin-  in'^liTt  ,,1'  tl.i 
il-i'lf  arnniiir  tlir  p'tinili  l)v  a  d 
wliirli   riainii'd 


lygiini'  was  \\v 


i"il:rd  alter  and  u  1 


111  Were 


(■    Mni|)l(st    li\^icini'    I 


iTiinatiiin    nf  thci 


nca-iircs   avcii 
r  arinv  hv  the  diM'; 


I) 


iii'irr   virtiins   than    nni>l<rt  and   sili: 


iirnit:   tlif   a|>|>ri)acli    nf  an   •■iiidcinii'   th 


freight   traffic   trmn    niiirlil 


passenger  as  will 


wliii'h    till'    imi- -1,111,1    ..hII 


"'I'm-'   i-iiinitrirs,   iiu'lndinir  all 


iililrrts    to 


Cliitl 

cilli":'  1(1'  I'M'Iiii 


l|llL^  wa-hiiij:,  and  Mnvthinir  that  is 


I'lv,    rci|nircs    tlir    iiii,>t    rarcfnl    att 


I'ntmn. 


dt 


■iis|)iri(,us  ill  this  rcs|i(.,.t  sliunld 


lii'liiiT   it 


iltoirftlicr  or  !)..  s,il,j,M.t(tl  to  a  systematic  d 


l>n)tcctioii 


•illowcil   to   pass  the   (Vonti 


I'asscniicr  Iratlic  cannot  nowaila\ 


in  the  d; 
vi-ion  hv 
to  tram] 
|(risiiiis,  r 
if  pos<;i,|,.    1 


ly 

s    ot 

Ian 

t 

IC     - 

iiiit: 

)S 

am 

1    N-a 

ai 

niai 

1     St: 

iiit('rru|)tcd,as  it  could  Crincrh 


"  <l"."-'>itnic;  it  can.  liow,.v.r,  l.c  kept  under  siip,.|- 
'i-y  piliec.  Attention  -hi, nil!  !«•  dir.vted  esp.rially 
i}r;il)oni|>    and    their    l,,di 


Itions,  etc.       I- 


m^rs,    to    taverns,  asvl 


inns. 


pos-ii.je,  l,e    lit    once    isolated    either   on    the    spot 


very  sii.-pieiuns  ease  ot'  diseiise  should. 


iiitahh 


hospital.       Kveii    the    d 


pot    or    in  the  nearest 


intected  rcLrioii<,  the   st 


weIlina->    of    hialtl 


rc<'ts  and  districts   in   I; 


i.v    miniijxrants    t'rom 


111  the  hahit  of  lodirin,,'  j,nd 


il'L'^e   citie-  where  tliev 


lire 


•  •arryinir  on  their  hn-ii 


•  •"iistant    saiiilar\-  -n 


ie>s,  ollirht  to  he  lindci 


|>'TVNion,  so  that   any  one  att.ickcd   l,v  the  di 


"I'ly  at  once   l,c   -.lit   to  the   nearest  hospital,  and,  if  |)ossif,lo,  tl 


le  other 


IJ 


i  'I 

Hi 


III 


;'t 


'-■- 

i' 

St; 


^^^-  TV  nils  ,i:n:i:. 


I'  i';ii-(t'iil 


i'.^^::.»in,..  .uJ:t:n:;:i:;:::;;v:::;;;;^ 
.:i:i''r,,,.';;,=i::';;;,:;i;:;:V v-'- -^h:^.:  :;'::.' ;^;r'r 

i.'./an.„„    In    .\|.,al„(  '     """"■''''"' ^^     '•'■''rr..,!    ,l„.,„    ,„   ,1... 

'    '-'l.'nk   „,,.,„;„„    i„    ,„.,i„^    ,l„.   .|,.i,,,|,i,i„    „,•,„,  ||_,„,.,„,i„.,, 

""■': ^--— '• -,"-!,„.  .,,i,i,.,„i.,  ,;„,„„,,„.,; ; 

IsolationiUn  -pin.  ,,nm   ,.v,.:H,n,,,.,,.,  „,...,,.., I,.,  .li.... 

;,"  '■:"""""^".'"' I— i,.i,„u  ,„',i„.  i„(;..,..,i  ,,.,n..,  .,,.1,1,.. 

'■"'7":'"'"'''"'^", ''■"""'"• ''--'-■-!  -■•|-.v,.n,in,n..w  ....„„„. 

:I;:::l;;;:r''''^''^^         -. "■''■•" .--i,... 

""""■/.■"■";':^"^"' '    '^1''"-    '— MMna, x,.l,Mv,.lv  ,n„„    ,„ 

'";""'"";■"■•; - '-'-n ii-„.an.i  „.,„„;,,,,.„,.„,, 

l''-;|'---Kr-|"-i,,nal  ,.,,!,,.   a ,,„•.,...,..,„,,„„„,„ _ 

P,t    ;:,'"•;, ^'    '"■    — 'l.n.,|    ,„    „„,    transportation   of 

patents.      ni,„„v,.,.  ,|„.  ,,,.,,...  i.  ,„,„,,.,|.,,„_     ,._ 

^'.":"'''  '"■^'•'- '"■"-'"•"•  "'—P'-ta-i ru,.!!-,!,- .,.„.,... 


II  imlcliniti'  ti'vcr. 

>   t''i'   Irans- 
iii   ia.-il\    1),. 


,;;;;.l^:;:t:;:r;-\;::::-;:;';;,;;:;J:-;'-i-: -:-■-■ 

ir  ilir  iviriilar  patmU  (l.-ii:,.,.,!  (;„•   d, 
1;m'-c   c-itic-.  ;i(ini 
I'f   tllr    (li-ca-c    -I 


111-    iinr|,(,-c   aic    iiia(lc,|iiat<.   in 
";'"•'  l"'""'~'^'"   ^"■'I'lainl..,!  will,  ,1,..   ,|„.,.ial   ,|an..,.r. 

;'"'"'''    '"■    '""•"--,..1  wi,|,  ,|„.  „.aM-,„„-ta.i, r  |,a,i,,„. 

:'"■'""- I''    -  '"■  I'f    .'.    P''li m,.iaU.,„a: a,..!...,.     ,.   ni,   .;. 

|;;'l;'v,.a,n^,,,h,.,.   ,.,,,,v,.van,.,.,aM,|    th,..  a-  uvll  a-   ,!„■  ,,.,nain,I.r  ,.f 

ii>lii'(l    l.v  i|i(.   Ii(,>j)ital-., 


til-    tonv.  and    ,.v,n    tlir  ua^^.n-,  ~|,„nl,|  '|„.    (■„,., 


i'i:"i'in  /  I.Ms, 


tun 


ati,|  i!i,.s,.  m..,  -.|„,„l,|  ;.|,.,  |,„|.,.  i,,  ,|„.  |„„,,j,.,|        I  I        ,    .  , 
.Nuiitai-y  -ii|.ii\  i.inii. 

■'''"■  ""•'•""!  ">■  l'"ii-i.ii;  a.hl    Mihitint:    ,1,,.   ,,atir„N,  il„.  ,.|„,i,,,  ,,„| 

Hrnn,..n„.„iuf„,.,-.l-  i„  ,|,..  I„.,,i,.|- „,  „f  .i,K_, ,„  •  ,  |„.i^^„„  , ^^  ^ 

a^  u.ll  a-  thr  >,n,at,oM  ar„l  i„„.n,al   aiT.-inw.,,,..,,!-  „f  l,„-,,„:,l-   ui||   1,,', 

''"'•""'■''  '"  ""•  -'■■■'i '  '!'r,.atM,.„t.  ,„„,|„.,.  „ith  o,)„,.„„,„.,,|     ,i„. 

'■'.''''-' ^'■'■^'•''  i"  ""■<■.•"■.■  of, ,atirn,-.       I„  ll„.  s,„„.  ,,|a.-,.„i||  |,„ 

(•iv,.,,  a  Iru  iM.,v-.arv  pivaiitio,,.  „|,i,.l,  ,|„,„|,|  |„,  ,,|,„,,,,,,  |,^.  ,,,,,__,  j^_ 

nnm,.,|,a„.  an,.,„lan,.,.   „„    ,|„.    |.a,i..Mt~_|,|,v,i,.iaM..  l,„-,,i,al  a,„.,„la,„. 

ami  Dtlicial-  ((iiiiirctcd  uilh  tli<-  in-iilnlioii.  ' 

lMn,H,lial,.|v  ail.r    a,l,„il,aM,v    ,„    ,i„.    |„„|.i„|    ,|„.    ,,a,i,.„,s   .l,„ul,I 

.■-.•iv.'al.atl,aM.II,..,.a,vtnlly,.|,.an-,.,l;    th.ir  ,l,„|,i„;,  a,,,!    nn.l.nv.ar 

■■' ''  ''*■  l"'"l"''''>   'li-i"li-'-l   Mn,|  k,.,„   in  I,,-.,,  u.i:-v,.nlila.,.,l    r,,,,,,,- 

at  ~o,„..  .iMan.T  ln,n,  thr  wanl-   „„,i|    ,|„,   ,,„i,,„    ],   ,|i,,|,„,.,„i       -,•,„. 

'';"",";:    ~ .'I'l    I-  'l—'l    in   .■io.hin,.   ,.n,vi,|,W    l,v  ,|,..  I,.:,,i,,l,  ,,„| 

> -,,1,1  I,,.  Mn,.,lv|,n,|,il,h,.,|fV,,,nn-in,anv,,, I,.,.  ,,,,,,,.,,,.      .V„v,,.,n 

"'-'-;1';.Im.^. .,-,., I,..,.  .,,;„,,  l,..|,.„.i„„  ,„  ,„..  pa,;,.,,,,  ,|,a,  ..„„;„,  i„. 

':'"'•    '''-""'•'•"•■'   ••'•  "'■•'!    i~  wur ,.  ,„,,,  „,   „,•  „„    ,^ ,_  ^,„„,,,,    ,,^ 

.l'Mn,y,.,||,y,in..       Iti~U>,.„-,ly,„|.av,l„.,,a,i,,.,,,.„„,|i,„,„,„„i,^. 

t"|--Mcll,|,.-.tni,-tl,,M,.f,l,,t||i„ir,|„„  ,,,,„„   ,|„,    ,.j,|^    ,, 

•  li^ti'irl  l,y  th,'    'iMv-anl  ,.f  il,i>  |„-,va,iti..„. 


it     lllfivtillir  :|n   Clltilf 

I-;v..n  i,,s„,all..r,„w„s,  u|,..,v   ,,„   ,i,„..    |,,   ,„,.„   ^i,.^,„   j;,^ 


;;;':::l;:;^:!r;^;":;,:';:,-,slt-;:;:,:;;.,^'""" 

.       ' '%"'"-'  ••?'■•■'■"'  'li'-'-'i""-  -I I.I  !.,■  ,riv..n  i„  ,vu,.nl  f.,  tl„.  wash- 
ing of  hospital  clothing,  ,,am.. .iv  .1,..,,  ,,ati..„ts  witl.  utluT 

<li-,'.-iv.   aiv    tivat,.,!    in    th,.   s.inc    in-titiiti,.ii. 


--.•;'v  .;::;,r;.,r:;;:ir,:;;:u:r;:,r:|  'r"'-''"'-  •■"■i  ■!"  '"""'■'•-'^^- 

..,•    I''  '^'"'  "'"'•»■■     '''I"  "■'■lit.  xihiiioii  ,,tCarl.,ili,> 
''  '    ■      '■    '"'iifi.  \vi    1   a  Ml  lit  ,111   (if  Iv-iol     ..i.,l    r-     ,   ■  1  <.uii,i,i, 

n|.'t.n.  ,.„u..r  ,.f,l,..  a„n,.,,,„.,i, 'ai.  a,i,l  lu.liev.Mllar;,'     a  ':;:;; 

k..pt  tr,i„,  .vmla.l  uitl.  .1,..  air  aiv  ,|„„|,|v  ,lan-,.r,n,< 


',".'-   '"■  .■•^i>"^^"r,.   t„   >,ip..,-iH,,l,Ml   >|,,,„,    |„.(;„,.  1 


wasluiiir. 


I'f  lifLriiiiiiiiL'-  the 


priicess  nt' 


III  iinler  t,i  pivvciit  t 


ic  cIijtliiMir  fniii,  lifciiiiiiiir  spottfil  hv  the  l„,ili 


*j.i''i 


'  ;') 


J 


(inn 


/■)  I'll  Is  1 1  \  in. 


i.^  wc.ll   to  urn;  II  w,.,,k  .«nl„li„„  ..|   .,,,|.  u.|-  u„|,  „  |i„|,.  „„|,,  ,, 


«w..H.r,.  Ti,i.  ,.r..,.a.Mi,.„.i.:.„..;:,.:;;,M ■';;.; ;:::':;;';"r';"'  '■'"■'""" 

villi I    1.1 1    .■  .  .  '••    ""     i'"\<l'l     iii;ci,  ri.ii>    >,,||,.| 


=;;ir;;::;:!::,;;:;rJ;:r:-::~^^^ 


''    ''"     iiili.iliiiaiii-  ;,||,1    i|„.    iiiiili,,. 


ilii-    cm     |,r      IM 


l-llMlr.l    I,,   ,|,,    ||„   i,. 


'"'■'■  :'"'""-"^'">-'- I 'M,.  ,„,„m.,.  ,,„i,i„.  n,-„„„i„„-t;„-,i„.,ii- 

'"!""'■'";'  '•'■•"'---"I  i-i-i-  ■--  .1,,.  L„M„i,i,-„ii,„-,,i„i „- 

"''"■;"^    •'",-"""    '"""'■"■•■'■'--    -ualN    ,,.,..,,.,1    ,„    |,nv:,„.|,„„.. 

'■■'II      I"'      ll-"l      t^T     llll-      |.III|,.,M'. 

_,^    ■'!''"." '    "'    ^isinf^'ctinff    washinK,    bed-linen.    :„„l 

outer  clothm«-,.„.M.  ,„  ,|„.  „-,.  „n,.  „  „,,„„   ;„  „„   „,„_, ^^  „ 

;''''"'■",'"    "; I—  null.  IV.        I,„.    :,„.l    l.all,,.,.  ,:„■„„.,„-,.: , 

!;:,  ""'■'""'  ' '■  !"• ■"•  -  ""-  -I-  ■'-I'l'-N  .1.-.,- 1 1,  i, 

"';"'""-', ■^"■''''"^    >iv:,„.,|.|,l,         ,i,.r  ,.,.,„.  ,.:,H,„l„.„i,,    ..lun,,,. 

=""'  'M'"-"'!   '"  'li-  .li'-  l-r  .-i   iininlMT  ,,|    ,|..,\,. 

,.';   ""•     ',"■    i""-^"ii^    ..M.„„.  ,!,:„, Inri,,.    r:v    .-v  |„.n.,i,.,.  |„   M,„|,i, 

"'"'■''; ''^"'-    ""■    '■""■'■'1'"" '•-"•.llll    M,.nli/;„i .V     K,„.|,     „; 

7'''"'''" 1''"''^  'IMiillvni,^,.|,.||,in.  ;,i,.|  nn,|,.ru,.:,rlu  .x |,,. 

''""'    ''"■    '■'■'■'"    ■""■    '■"""    li-m-    I..    :.    nn,|„.n,l,nv    „f    ||m'     ,„     ||..' 
<  ■   ■"    ■■'    ~l"''i^ill.v    .-ii-ln„.,,.|    ;,|,,,:M;,tn-.       Tl,.    rl,„|,in,    u,-,-     ,„„    ,i',| 

":r"""'' ,'"    ' "'■-■'""     '"'"^    <nv.  .„•.,     1,...,    „;,.    ,,,,„,,„,    j„    |„„,^. 

':'';■:""'    ''"-'^l l""l„.|.,.a,   ,„n,.h    i,,,!,,.-.,,,,.  u.v;.   ,1,..    „.:i„.- 

'■"'    '~   ■■"■'■••"'-"''    III    -ll.'|'l''-'l'    IIH'>lln,|.,r, ,■,.,„„.,„    ui,|,    liv,.    -,..-l,l, 

,       ""• '''-""■'••■'! fl-.l-.  liL,.  ,lia,,„-,h,.  1„„K    li,„.„.  ,| ,1    |,„,1„„., 

''■''"■/"■'""■       l!l^iiil-l-.   Iiillou-,  ..nMl    n,:mr f  anv  U,„|    niav   I,.. 

i'Ni"-.l    witl,„ul    Mitlinn^   a„v    ,1: .,,       |.;,,.„    |,,,„    |,;„|.„.,.|^    ^i,,,,,, 


>liiiiil(i  .■ilua\-   1m'  of  ih,.   i;,|,| 


"-    ^'lll-'.^     ill     •I'Mrlni,'     lln-|,il;||,.    I, lav    l„- 


•"'"'-'■';"    '"■'    ^"'^""        ^\' 1'"    l""l^"-'l~    -l-nM    1„.   ,ak,.n  a,,ar,'an,l 

'■^l'""'''    '"    ill''   •■III-    \''<y  a    iiiiinlirr  of'  i|a\.. 

IiUKHn.  ,i|,^  l,.n,|„„.arv  l„.,,i,al.  a,„l  ul„.,„.v,.r  M,(ii,.i,.,„lv  lap.v.lM,,. 

•in  nil,,  ,>  ,t  1,„|,  valii...  ih,.v  ina.v  U-  ,|.s,n,v,.,i  l,v  (iiv  ;  Mank,.|<  ,.„v,.r 
mtrs  a,„l  „,1„.,-  ,iM,..nal>  inav  1,..  ,li.intl...,n|  l,v  l.„ili„^  ;  l,lai,k,.,'  Van  ,: 
.l.sii,f,.,.„.,|  l,v  „„,r,|y  ,.x|„Mi„^  tl„.,„  l„  tl,..  ..„n  lor  a  Iru  ,lavs. 

n,,.  ,,„v  „!■  other  articles  used  by  patients  i,  1,-.  i„i,.,.rtaMt 
'"  '.v|,l,ii.   (,.v,r  than   in  many  .,tl„  ,■  a.aii,.   int;.-ti,.,i>  .lis,,a--L-.      l'lat,> 


ri:nrin  /  ia/v. 


liOli 


n(|iiiiv   ,,i,lv    siii-hj,,::    j„    |„ 


•t  u.ii.r,    a-    till 


ill    till-   tic,., 

a-  llial  (if  the  uiImt 
'•    '"    ""■   l""~""    "I    '.M'Ini-    t.A.r    i,    iM,|,.,(i.,.rlv 


kI.iv-cs,    ~|k»,ih,    ;i,„|    i;,rl^, 

l-l-,.an-.  .,„.,.„„..„  .la.-..-..,„l  u„.  ,..,.1„..,,,  .| ,,,  „,.„,„„.^„    ,,,,^.,^_.^; 

(Hllv    <l,aM..|    a„.|    .liMnli,,,..!    „,,!,    K  ,„|    ,„|,„,„„    „,   ,.|,,„,„,    „,-   ,„,,,. 

'"•     -"'';'"|'-    ; -•■    ' I.    I an,,.,,,,,-    n    ,„    „„,„„, 

:iiiil  iiijiii'. 

■I'li.'.AM.I   ivlalion  ..(,!,.■  i;.,,..  aii.l  iini     ,  :,-  „,. 
'^'■IVtioM,    of   ill,.    |„„K,    ,,,    ||„.    |„„,,„,    ^,|. 

'"';""•     ■'■''-"•"'-   '    '"■''•-'■•'■'•I'-,   ,la„„.,.„ii-,.|i,l,.,|,„  ,„.,,„ 

T"  .'"";;'":'    '"■'-''"•^'" ''  — •   ■'■  '■■■-'■M   an,.„„„„   ,„  ,|i,.  ,,.. 

;'"""'■'"::•      ■^■■'■:-'"-M^.i--a,l,|  lMn.,.,.,a„.,„,|„...|„., 

:;  'V"^:''7 ':''■'''- ^'''•■•- >"'■'''''- '"-I''-'-''- '-■-..  i,:iv,.,ii,.,,. 

s|>"iii;i-<l  w  itli  lininK  . 

Typhus  cadavers  ,1 ,  ,..,,,.,....,■  ,„  1„.  ,,,.,.„„, ,,,,^,„„,  .  „„^ 

::::,:::' rT -.-,;„.„.„.„„.. ,.i,.ii,ii,.  ,,„.,„  ,,„,.„,, 

"■"'•'■••';■'"•■'"•  ^"■'.""''" -"'--l..!...,,    in  ..1,„|„  .,„... i,||     ,,„ 

r; '—   "^IW-, il.liaM- .,,,,1 ,,       , 

-I'    =..-,n,Mnl.,.,.,,,a,,,.,,M,..a,,,||ia, ,  a  ...in n,  in  .  I^.|,  „. 

a,t,.,„laM,>.  '    ""'■'■"""" ^  "'••  l-l--n-.  ..,. 


TUv  disinfection  of  wards  ,> 


1   private  sick-rooms  aCt.i  ih,. 


.      '"""■'nst,,Ia-..,|i,.,,H.„.,,l„„.|,i    ,.,„  1„,  k.,,„  ..,,_,   ,;,;,^.,„_,„ 

.    .......PS    ,laM,..,.,    a.ul    ,„|„.,.    v,.n,-li„l,.,.      I,,    .h,.   ....,,.„ '„„ 

^...•n.;v,.^.v..iH,u„i,.|,„,, „,,.,,.„, ,  ,,_;■  "" 

Dsxnftton  of  Furnishings.- A,-,..  v,.„nla,i„„  ...  , .,. 

' '     '"'   ""•'"'"-••M-tun.s  a,,,!   „tl„.,.   ,„.,.„,„.,..   „„   ,1,..   .,.„.    .,,. 

f.iii,iv.",|.  aii,l  t „.  wall-   a^  u,.||  ..^  ,1,  i-  ,-         , 

"  .  ,  a>  u,  I    a>  III..  ,.,.,l,„j;.  ,„1,|,.,.„.,1  ,„  a  ,,,n.ti,l  ,iis- 

'  ;•       "■'''-"'■<•'-'.   .,r,l„ ilin^  i-   „„„.|,   ,„.„■,.   „......a.-v  in 

-    .•v..   ,l.a,,,n  HKH..  ,,r  ,1,,,  ,,,,,.,,,  .,,,^ 

'    7'"^   7"'    ;"''"'^^  •■"••■   l'='l'-'-    tl..,v   .I,,,,,,,,    ,„,   ,,„,,„„,   ,,„„„   ^^,„, 

:;;''-;■ ':-'';'^ -•-''-<-..■•■  ...vtunv  ,.„„,.,.„.,„„ ,„..,,     ■ 


I 


I' 


*    .1 


till) 


/  1  fill  ■>  I  lA  i.i: 


i 

m 

\ 

:,..;., 


-ra,..,i.,ii:,i,.,„t;.„.,i„„i,  ,.|,i„,i,i„r  ii„„,,,„i  „■,.;,„, i,„  .  ,v,.-i,  ,„„ 

"I      ullll,   W.i-li. 

''';'■     "'""■     '-     -'■'■"'''•"'     ■-'""ll>      "'tl,     -,.n     -„:,,,    .,,,,1     ,:„l„.|„.      „,.| 

-|"->    :M„nn„„   l„  .,,.   |,:„.|  ,„, In    .,„„„,;  ,M-  :,n.ruar.|   n.l.l„.,|  „,)■  „„| 
»:i\'  'I  "I    |iaiiilii|. 

'"'■,""":''  """"""    ■""'  l""nMnv|,.n,„,|„„h  ,.,l  -l,..„l,l  l„    „,,.|„,,| 


"itii  J  :i  to  -I  III  I   r,  ni.  „, 


""■•"   ■■'    ■■ai-l".lh     M,„|.       \-;,nH.|„,|    ;,,„! 


.-l-l,.M-.-a,vl.,.„,.|,„„.,|,„|,  |„v:„l.      TI„.s,M„.,„., I,-,,„,,|„',.,, 

"'"'^^"-'"■''''"•""■'-""'■•■•"-.■■'li-'nnM.-.  :,M.l   ,|„i,    Ir ' 

,        ",   ""■   ;"'■'";"'■•■    ;-    "rl-l--,|.    ,|,„    ,.„„,i,„    , ,1.1    ,„.    ,,„,„„^,„| 

'";;'""■;' ■'  '-''-'t,.,.,..,i  I.  i,oiii,„,„„i„„„„,„„  ,„„^,.  ,„^,,,._ 

■■'■;'""";'.  """''''•, ■'"■"^—-i-:iji„.  „,•  ,i„. ,„,i,„i-„..,  .„,, 

7"-  "'';•"    "':"■"    ''■'-    '■"■ In..,.,   ,,„||„n„n.  .    ,„„.,.K    i„:„l,.,,„a,..   „. 

«l<'.-lr.y  llio  |K,i-(.n  m|'  |\|,|mi-  |i  \ ,  r. 

.\-i.   U,.n,.,.m1u„K   ,|im,.Ml,    —linni;...,  „,.,!,.„  ,„„„,,al-;„„|„,,|,„,. 
Mm.    „l,„...,,^.,,„,,|,,,„    ,-a,iv,-al,l..,„,,.n,„v,.alll„„,l„.,„„-,   , ,,.,.,.,- 

'"    •';'■    'I'-mti-ti,,,,    ..r  -hi,,-,  railrna.l    ,..„.-.  a,„l    srU\r\,..    ,1,,,     U-.y', 

I.. ■-..  M-,.|  |,vu|,|,n-  ,;..,.,.  ,.a,i,n,-.,l„.  ,n,.,|„„l-  ,,,,.-,.nl.,..|  .;,r,K...lli„„.. 
=""'  liiriiin,,.,.  „ill  -Mlli,.,.  ui,l,  |„.,,|„.r  „„„li(i,.ati,,M-. 

,        '•'-'"'■'■'■'i n„.-,,i,,l    „,.„.,U    |„    .;,nnal,|..U,|.  ul,i,.l,    I,a.    „„,,,„1, 

'"'""    '■"■■""M„.,„l,.,|,  l,a-    n,.v,.rl,....n,rinl    in  ,v  ,,1,,,-  ,;,,..,.       ,.■,,„„  „,,.;, 
w.'know,,,    'I-  na,nn.„C,|,„,,„|,„„i,  .,.,„,.  |„,,,,.,|,|„  „,.,,, i^.^^^^^^l^^^^l 

"•;;;''    '"■;''<;-.       I-    l-    nn.,.l,    ,„   1,„  l,,,,,,.,,    „.„    -ar-tMl  ,..,..  n,,,,.,,,, 
will  I..'  hkhI,.   ,lnn,„.    ,1,..  ...M  ,.,.i,I..,„i,.,   -i,,,-,..   i|    ,1,,...   ,,,„v,.  .Urrr-.M 
'l-|"--Ht  ntl,..r,.,„n|,li,.,„,|„„.a-ur,.-uil|l„.  i,„M„:„-,.lv>i,„,,ii(i,.|. 
Tlu.  ,ii.ini;.,.,i„„   nf  |„.i,a„.  I,„u....,., ,  l„.,.a,.n,.,l  „„,    M.r,., --tnl  Iv  l,v 

,';':.;;:':: i""/""'^'";;  '■^'■■' '''■•■''-- -'''-ii-n.ion,,,.,.':!..,!, 

,'"„'";"    N"-:;  Iv    -ran,,.,!    ar.    ,„a,.,i..ally    alu,.s    .;.,m„I    ,o    |„. 

1.     fh.uk  u  ,„-,    -..rv,..,.>  ,.a„   I,..  „l„aiM,.,l  l.v  a,,|,li..ali„M    ,„   ||,..  |!„.„.,1    „,• 

i,;,,,,;'.;;:'"""-^ '■'    '"■'"■^"■',,■,..,1    |,n,,,..rlv  M,„i   .InHnl    i,,    ,1,..  ........ssu-v 

Rcgrulations  Regarding  the  Discharge  of  Convalescents 

-IVlor,.  all„u  „„•  ,.„„val..-,.,.„,,  „,  ,„„„,,  ,„  ,|,„i,.  ,:„„i|i,.,  „„|  ,„  j,,.;^.^,,,, 

''*'■    "    -'"'"'''    ■"■    '•.■nu.-„l.,.,v.|    ,!,a,    ,|„  V    ,,,   ,,,,,, I, ,.    ,,.,,,,.i,„,    ,,,,, 

I"";''"    ''    ''"■    ' -n-v  p,v..an,i„n-    l,av,.    1,,.,.,,    n,.irl..,.„.,l.  j,,-,    a-   ntl,,.,- 

..•;,ltl,v  |„.r-„„-  n,av,|„  if  ,|„  v  hav „„.    in    ronta,.,  ^w,h    pan,.,,,-  or 

l,a\-,.  li,.|.|i  in  an  int,.c,,.<|  \va,-il. 

'■"'"■   -"'■'■'•''    '^■■'>'^    '"■*'"■'■   '!"•>•   ^"v   <li-,.|,a,-,.|    vai..-,v,„s   s1„m,1.1 


t.lk 


'•  "irMi  \ki 


!,M!l 


1.    Vvii) 


II:" I 'in  I  I  \/> 


.iiiiiiii/..ii  -.i:i|,  Mild 


•ill 


>,nvcM    (.,    tl 


r    ■  (.■:ili-iii: 


!•  ■""'    "^IKT,  .■arrlMl  utfrllti.,,1   l„ 


"tlltT    IkuI 


>  p'TiiMii,  ,,r  ill,.  i„ 


at     ,   ,1 


l-l.'lllic     I 


""'  •li«inl-.tini,   ,,(•  ,i„.   I,.,,..  |,.,„,| 
'■       'I'l"'    !:.-!    I,ath    -.|„,„|,|    I,..    ,,,1^ 


li'MI     III 


••N.    it 


'■'""■'"""■"■•'I     I'.V    |.MlPrMl-     ,,r     ll 

tlii>  filial  linili,  til,.  ,.,„|\;,|,,„ 


'■      iHPMlll.ll       |„ 


I  |iia<'..  tliai 


fia»    lint 


Kir  liclMML'mj.'^.       \t"tir   t| 


M 


'■'"'liiiiR   if"  Itii..   |m>;    I 


■nt-  AT<-  t(i  i\ 


r*'  -i  in  111  M  i|(,i| 


■rila.I  Willi  III,.  j,„i,,.,„  ,,,•  ji,,.  ^j 


"■••n   carfliiilv  .li-ini;,,,  ,|  .,,„| 


iiv  liavf  takni 
li'iL'.  IT  in  ilirir 


|il(-ri\|.,|    ti 


i.-caH'. 


>iii 


li 


llv 


^^mm 


c'^(< 


treata;ent. 

SPECIFIC    TREATMENT. 

I':-  to  the  |.n-...ni  liin.'tluT,'  Imvo  Iuhm  mo  M..lcw<irthy  atteiiiiii-  at 
.-^[Mvilic  tivaliiiciil  uf  lypliii^  tcviT  in  tlic  nKidcni  -cii-i'. 

Kven  tlic  opid.niic  M|,|>r;naiMv  .,f  the  .li-casf  in  Fran<T  in  ISti;!  dnv>^ 
iiMt  appear  tc  liavc  I.-.I  t,,  any  ra.vfiil  alimipt-  in  tliis  .linvti,,,,,  altlum^rh 
a  niirnl.tT  ..f  Fivn.'li  pliy-ician-  vv,  iv  at  the  time  u,ll  tniiiu'.l  ai:.l  r.,m- 
pftont  ti'    ;iai<c  tlio  necessary  eX|)erinients. 

Tlie  faet  that  it  is  so  danp'roii-  a  .|i-ease  that  the  mortality  js  ihrr.. 
tiiM,-  as  i:n,,t  as  it  is  front  typhoid  lever  should  indnee  ns  t.Mlevi>,.  new 
and  more  .■Hieient  methods  of  treatment   than  those  at  present  in  u^v. 

Even  the  maiiilest  .iilHeulti..s  eiieountered  in  the  studv  nf  the  nature 
an,l  hfednsiury  of  ih,.  cause  nf  typhus  fever  and  the  ahsence',.f  nnv  definite 
knowledge  ,u  re-ard  to  it  simuhl  nut  det.-  ns  in  future  epide.nirs  from 
niaknit,' experiments  m  immunization  and  seiotheiajiv.  We  nu-ht  f)  feel 
.■n.'oura,ire,l  hy  the  resuhs  of  vaccination  in  preventhiL'  small-pox  and  hv 
the  famous  acnevementH  of  Pasteur  in  the  (.valn.ent  an.l  prevention  of 
rahips.  W  helher  experiments  in  connection  N\ith  Ivphiis  fever  will  nls,»  he 
crowne.1  l.y  success  and  ,.f  what  nature  the  r.^snlts  o'f  iLcse  experiments  will 
!«■  cannot,  of  .ourse,  he  predicted  to-day.  I  have  alrea.lv.  in  the  .haoler  on 
the  treatment  of  typhoid  fever,  ha.l  o.easion  to  point  out  •  iie  thllaev  o<- reason- 
niL'  by  analoiry.  and  I  feel  impelled  to  repeal  the  warninj:  in  this' place. 

.\~  opinions  in  re-ard  to  th..  nature  of  tvpdnrs  fever  ehan^re,!,  niimer- 
'Ml-  attempts  were  mad.,  to  diort.'M  or  alM.rt  th..  .iisease  hv  l.h..,<!-l..ttinj: 
hy  em.ti,-.  .an,!  hy  a  hrn^  htLs  .,f  .p..,.iiie  .|n,-s,  M,..h"as  .piinin  aii.l 
.'theix       .Ml  th.'M.  m.lho,!-  hav..  now  he.ii  ai.an.lon,-.l. 

.•\n  inter..stin:^  paragraph  on  this  suhj.-ct  is  found  in  Mihicnhran.rg  fan,.,us 
nmno-raph,  which  .lat.-s  from  th.-  hei:inninfr  .,f  the  pivsent  cntnrv  n,„l  I  .,m 
temple,!  to  .pi,,te  a  few  <.s|H.ciallv  pr..<:nant  s.nt.n.-.'s  fn.m  this  work  ' 

■Atl.-r  a  dispassionate  siirvyofall  th.-se  hvpothetie  method,  of  ireat- 
nuMit,  It  IS  noie.l  at  .,n..e  how  shortdiv.'d  th.'V  were,  how  litlle.  th.Tefore  was 
their  true  value,  an,!  how  ina,l...piale  lh,.v'wer..  in  pnuni.'e.  We  mav  in 
the  tiiture  ..x|K>,.t  as  many  mor,.  sm-h  .h.eirines  ami  svstems  of  thcrai.eulics 
as  Ih.re  n  i !  he  hotdiea.ls  ami  visionari..s  in  our  art.  J5ut  if  on  the  c,,;.- 
trarv,  w,.  (,,|  ,,w  ll„.  ,,a,h  of  ,.l,v.rva!ion  an,l  sn.'.vssful  experi.n,-,.  ,n  ih.'se 
'.ises^ni  .,tli,.r  w,ir,ls.  il„.  pail,  ,,f  ,.„,pirieism  -ui.le,!  l.v  r..ason— our  fre.. 
an,l  un.ra,nn,..I..,|  in,L.m,..„  will  l,,,.l  us  on  to  new  an,|  h..tter  view,  than 
ean  l,e  h,,p..,l    t,,r  fr,,,,,  a  l,rain  that  is  rnhMl    hv  hyp,,thes..s." 

'  /.-..-.'  ,  1.    I7>i. 
AI2 


Ti!i:.iT.\f/:\T. 


613 


;:::r: -'•;:-'"•—"■ ...•.., rt..,.,!,;.,  . 

lyMln..   n^:,,..,   ,..,,,,,,.,,,   , ..I.n.i...  .,,,1   ,„„...„...„,„..,„  ,.,: 


GENERAL  TREATMENT,  NURSING,  AND    DIET. 

ti  caM'-i 

liMlicnts  to  l)(d 

■  Ix'^niining  that 

lii'ir  DWii  accord. 

n-  .hat  absolute  rest  in  bed  ,l„rin,r  ,i„. 


'>win,,o.l,cin,cM-i,v,,r,|,,.i,i,i,,     ,,.,,,,,,,.,,   _,.^.,,,, 
""•"""" ""''I-  i'  -  nuvlv  necessary  „,  onlcr  ,|,c 


It  p...  u.thou,  s,.,.n.-  ,l,at  absolute  rest  in  bed  ,l„rin,.  .l. 

7"- ""• " '-■^' "'♦'■•■-    l..:.st  a  wccl<afh.r,lH.c:. 

sc\cii'  iiitcclKiiis  disease. 

-|''-N^i.oMldn.,,l.eall.ue.ln..M,p,evennl,ile,l,e  ,-el,.„,i„. 

,       7"''^"'^'"'-  '"•;' '''-.■H.eall,.v.n„,et  „„,„,■  1,: 

.::;,:;;:''':; ''''':■''''':• ' >"•"'■•'--"..■ '.^a-pa,.  a„., 

"11"'     ii"tlle  ti.Mii   the  vcrv  heuiiiiiiiiir. 

'';    ""■  -•'•'";'• -"t   :>fthc   l..r,he   .;,r,ner  hal.its   ..f  ,)„   „a.i,.nt 
may  he   .nn-ulle,!    to   a   c<.rtai.i    cv-enf        I,     l       n    ,  |>.ili.iit> 

.,,,,1  ,,.„,.,.    I  ,      .  '■""•      'f   ^' I''   I"'   iii<..lenitclv  ,.,M,1 

,   ;        :        '^'V'";     "'■•,     "-  ^'"    '•-'•>— nd    hed    should    he 

'     -    '-.I  ow  the   ,,at,e„t    to  Chan...      If,    pn.lon,.|  and 

'  Xk;;or  'V;:'"';''""'^ —•.,..,  n'o,nth:o..tset 

a.';.  l'  t..^T,       T ^'~   '->^'  -'  --y  -  |.<-il.l-.        It  should 

.ri..,!.;;,:?:  ■::::'   ■' ^ --"•--I.patientandal the 

''"'"■   l"'"''i'-"  "f  .larkeiiiMir  th..   room    Cnnerlv  ,-,  i    .    ■ 

Inrmfiil  .,     i       ,         ■       .,,       .       .  '"•'"""" '.^    "■'•"Muneiidcd,  is   jis 

'i.iiinliil  a>  I.  e\ce-Mvc  iMiiiniiial  (HI        It    |,   ,„,i,.  „  , 

rz::::::z;:., > t:;:::::z:  :-■;;: 

'"'"■  ''"^'''"'  """"^";'-  ~ '■'■  "•  I"-i'-l<'.  !>'■  individual,  who  have 

■   '•■/'"    :"'^"''^    •■'■' i>.'M>-;    although    Mich 


hrell     rcliih^rcd     i 


llllillllMe    li\ 


-.:-.'i;;;:J;. ;;■;;:: '- -- >.i->- 

I>i'nii:;a    h,r::e,.|,i,lei,ucaM,li„  ,>l•„.es^>|„.^.  thcllr,      '  .      ■ 


■I 


SS-:i«ife 


614 


rvi'iirs  Fi:\i_,;, 


It,-   <■(lllr^»■  I 

(■\ct»i\.' 

111'".    :lll(l.    .-I  ,■    ;| 


'•■•        .h..wIkU    rn,„i,.-.„.,|    |,v    |,r„„.,.,„,.    tlK.MtU..„l:,„t>tVo,„ 
jrem-nil   |H,|„il:ilin„.  ni.v.n,    ,,||,,«,.,|   „,   „nii-K'v,ili    ih,. 


ll ilie 

,.'""■;":"':  "'''■'  'f "' <■  ""■  i--- 1-  i,,,, ii,,„, ,,;. ; ,... 

xmII    Im.  .Iivii-,.,!  in  ,|,.t,-,il  Ciiril,,.,-.,,,  ' 

.-ulMt   ..Tan,,..,,.,,,.  .,v  ,„...,.s,n    ,;„•   In-    „w I,:,,.,,,,,   , ,,,, 

"    7'-'lv"l-.   Mn.lh,..ns,l,l..,;„.   tl a,v   ,„•„„.„,' i.,„/ 

"  '"•;■  '''^'"'-  '■;•'"'■'■•'  '"• """-- 'i'--"y  p- -in..,,,  „,.•„„.,• 

; :"•""--;-';-■  .■.-,.■,.,!.      Tl,i-  ,„v,.an,ion  i.  M,.,n.  ,K.,...,arv  i.v,,, 

t  — "  .y,.l:..,l  f.v..,..  Any  pl,v-i,.i.n„f  ,..,..„.!..,„...  knows  h„;vH„.h 
"l'.l'-ts  ...,l  tl...  ,.nau.i„;„i„„  „,■  ,1,,.  .h.liri,,,,-  p.-m,.,,,,  .,,,1  ,„  wlut  •„. 
<'x.>nt  ,  ,..v  ..,,„.,•  in,,,  hi.  l,:,llu..i„ati„M..  ...n,v.„.  l,i.  .l„liH,„n  ,„  ,|,.. 
•""'"   "'    '"^""^'-   ■""'    'l"i-  ;:iv,.   ,-,•>,.  ,„   i„..al,.„lMl,l,.   l,,,nn 

..,.;:i;::''M:''i:,:i:;:;:::rt:::-;;;;\.r:;:-^^^ 

All    w„„l.„    ,,|,j„.,,,    1,1,,,,^,,,.,   „.,„,„,^.    „,,,.,^^.  ,^_    ^.__^^^   „,.l,.,l.,.,n.,l 
♦".'■"""-■  -"'   """-•  "l>.i<-'>   ..'   wl,i,.l,    ,1,..   ,.„i.„,  a.    w..   know.  ..|in.s 

witlMlu.  ^n.at.Mol,-,ina,.y.>l, 1    l.„  ,„ v,..l  a.  on.v  tV ,!„.  ,.,„.;' 

1     ;-..vunwtan,...    ,,..nnit.tlH.   .a,-,,..,-    .1 1.|    ,„.    ,„,,,,.,„,    |,,  ,inol,.n,n' 

wliicli  I-  .■asily  (hansel  and  di-inllricl. 

Tl„...    |,r....aniio„s,  ..ft.,,  .•am,,]   ,.„  „i,h  .|i„i.,,|tv  i„  p.-ivaf   nr-u-- 
'"■'■•  ^..■;;  P.-1-.l.v  0I-.TV...I  in  all  u,.li-r..rMla.,.,|  ho.pilals,  l,nt   thcT,.  .„v 

""'^'  ''"■'■""";-  '"  '' -•-'  i"   '•'■.^^"•'f  "•  '1...  ,,la..in..  of  ,1...  ,,ati..„t- 

Removal  to  Hospitals.-\VI„.,„.v,.,.  i,   i.  at  all  po-.ihi,.!  ,v,.i,„s 

<.'vrr  patnnt-  -l,onl,ln,„  I,..  a.ln,i,t..|  to  o.,,.,,.al  ho-pi.al-,  l,nt  if  ,|,is 
"■'"'".";  '"■  ^'^""''^'-  ''  "'"~f  ^"  >'■-'  '"■  n.,n,.,nl„.-..|  ,|,a,  n,..>v  isolation  in 
;l"-,al   wanl.  n..ar  tl,.,..  o....npi...|   l,v  o,!,,.,-  p„i,.nt-  .io..s   „,„   .„.li..,. 

''";   '"'"•="■'•  '''■'-^'•' '■  '■^"'"•i".'   <•>-.    Ix'   "I'lain.Hl   „nlv    l,v    phuin.r   ,i„' 

I>|'t.<;-.ts  n,  a  -p,vial  nan!  at  son,,,  .lis.an...  (Von,  all  th.  o.h.r.-if  p..,i. 
'.l'^  .t  -i.onl.i  1...  at  tl,,.  ,op  of  ,1,,.  l,,,i|,|i,,.  ,,,,1  ,,,,,,..  I,,,,  ^^ .,,,  ^^  ^^  '   _.._ 


(Miti'ani'.', 


i])arat(.' 


It  is  ahvay-  n.n.l,  l,..,t..,-  „,  l,av,.  -p,...ial  ..pi.I.,,,!.,  |,„.,,|„,,  ,„.  j^,,,^,,,,,, 


l>iiiMiiii:~  cMrmci'trd  uiih  tl 


ri:i:.\rMi:sT. 


"■  ,i:'ii''i-;il  liM-|,it.i|,  ,,,!,. I 


(iir, 


I  :i-  ;irc  in  iiM     ill   ;||| 


III    ih 


••"ii-tnicii,,ii    ,,|'    I, nil, I 


r<'<c|iii,,ii  ,,(  ,,ii:ill- 


i'l^:-    "f   tlii>    kiii.l. 


I'"'  =""'  '>l'''">  'ivrr  |Kair,it>,  the  harnicl. 


"ij;nc(l    tlir    tl 


le 


I"'  |nvt,.nv,|.      \i   ,„,  |„ii,ia,i,iit 


'ii-triKiid  oil  il 


|>c>t-l 


l<— >v,-t(iii  i- 


i"ii>f  i-  axailalil 


ii~  ^y~iriii  ca-ilx  and 


!■,  \\ari|~  cai 


iiM>|>iial-   I 


-day — I    iiivil 


i'i|"<lly;  iiiaii\  (,(i||,.  I,,,, 


t  iliidcii 


liirir  r\i-i.iicc  a~  Miak. 


rclii  (iiily  lo  ill 
lili-  "f  tlii~  kind. 


az;iivtt..   ill    .Mi.aliii 


■jTiin 


Ventilation — I'l,,.  I.airack,-.- 


'•:irrviii;r  ,,iit    prrfrrt  v.iiiilati 


y.-t..|ii  air.iids  the  nadi..~i   in.an>  ,,f 


tlirir  allind 


on,  su    nrcosarv  Cr  liotli   tl 


Mi!aiit~. 


piiticnts   and 


T 


!<•     \M 


-llrjllll 


'"I'ws   >lioiild    l„.  „,„,,    l.v  dav  and    nj.d 


mil 


'«■    '■'-rrc>|.,,]idiii;,|v    ini'iva-rd 


'!'•'■  >|'.-i>"M-.   ,,f  i|„.  year    I    nial. 


Iiralilli;'     (iicil 


It  ;  HI  winter  tlicrc 
i'ii-.       Dnriii.r   tl,,, 


I.'   ill 


'■  iijx'ii    air.  111 


!«■  M   jinn-iici'  ot' 


Open-air  Treatment 


l'i"|M.rly  prot.ct.Ml   ai,raiii,f   <„ii  and  n 


•■•I'liiir   niy  patients 


"'7-:"'' '?■'"""•"'•     •\>" ^1'  tlie  l,.,pe  I  .,,„,„i„..,,  i 


re<lneini;tlie  I 
t.>  I 


ever  liv  (Ills  111 


'""i""t    siy  tu(,  iiiiieli    ill    (;,v.,r  of  liie 
II  the  l><'j,'iiiiiiii<,'-(,f 


i:'vea  veiy  tavoniM,.  .tlivt  on  tl 
■I 


'"'IIS  w a- never  ivaiized,  tin 


|iroeediire  pruxcd 


<'v<Telv  iinplieated   in    typlins   fever.      Tl 


le  nervous  M-teiii.  wlii.^li  is  al 


wavs  so 


tlie  -yinpt,,|„,  ,,f  ,1,,,  j,,;, 


lal  >lai:e — ti 


"'   P'"i''iits   Ixvanie  cpiiet,  and 


"'■IV  more   (iivoral.ly  iiiHiiene,.]    1,^-  t| 


II'  violent  iieadaelie  and 


insomnia — 


"tlier  mean-.      'J"|i 


melit;il  eoiiditioii  of  vii 


'■  intensity  of  the  d 


IV  aiiv 


Mioroiis  and 


very  favoraiily  in(ln<n,„|. 


"■  "pi'ii-air  treatment    than  I 
'•""•il"!'  «a,  hel.l  in  ,.|,„k,  and  tli, 
'•"niatM>e  patients  ,,ftei,  s.niled  to  I., 


Th 


as  a  direetlv 


'|«'n-air  meth.Ml  is  of  vaiiu.  not  oiil 


y  as  a  s\ni 


to  tl 
d 


'iirative,  treatment, 


ptoniatie.  lint  al> 


!'■  '■'■iitral    iiervoii-   -v.-tem    I 


•^mce  we   known  that    the  .■hief  d: 


'It'pres- 


K's    III  exce.-siV( 


i'\<'itatioii  or  e\ 


iiiji-er 
eessivt' 


Aside  from    the  henefil     to  th, 


"|"'''-:i"i'  treatment   al?;,rd 
til''    spread    of  the    di>ea-e. 


patient,  thoroiiid\  vent 


""■  ""'>t    etre<.tiial  mean-  of  m,ard 


ilafioii   and  tin 


iiij:  a<r.iiii>t 


It 


slllirle  111 


is  to  the  strict  use  of 


tlie,«e  iiie; 


who  coiitrMei 


I'I'ysieiaii  was  iiifeeled,  aii.l  thai  t 


ires  that  I  at! 


nliiitetlie  fael  that  i 


the    (II: 


iroiii    l,s7(i  ,,,  i.Hjs, 
"<'re   adiiiiitcl   to   M 


ease    was   ( 


K'  pereenlaire  of  hospiial  att 


"lien    all    tl 


le  ea 


:'.'".l"ritv  of  Ihe  hospital    inf 


"•'iliil  ami    treated  hv  tl 


''>ll-'pleiioiis|y  low   ihiriii-   the   ll 
ses  of  ty|)liii.s  fever 


lot  a 
eiidants 


iree  veans 


iirriiiir  in  Berlin 


P' 
Iiviiliiids   had 


if  tl 


mlers  thai   t 


teetioMs   that  did 


"'  "peii-air  method.      Tl 


not    neirlecled 


occur  iiiiLdit  have  1 


le   irreat 
X'eii    a\-oi(led 


!'■    Mece.s.sarv  hatl 


war!s,    iii.^tc.ad    o|'   in    tl 


IS   Were  to 


"V""'.''"' '■      '    '""'    ''^•^""■'l   -irict 


>«'   LTiveii   exclusively  in   the   I 


if  lli 


t'   alteiidants 


"'    "■•"■'■""■  "I  I riy  ventilated    I)atl 


who  ciiiiiract 


repeatedly  lu-lecti-d   to  ul 


I  lie    di.sease    h 


lev  tins  or 


mi,   inerelv  out  of 


I  rye 
■rooms.      Most 


laziiie.ss. 


m  '/■ 


m£ 


SI 


616 


rvi-nrs  r/.v/,/;. 


F  limy  rcrimrk  tli.it  I  ; 


"■'"."""'    ^^'"'   '•""'•   '•--!■    -.i.-.       I    ..„    ,,1,.,.,..,!    , ,..   „      "'"'   " 

:n::::;;::;:-^:::-,:;;;- 

-.■;:>n.i.-....;;::;r:;::;;:,:::;:';::'''- "--■--<•<• 

Diet        iV.,iH  in,,, ,,,,,,  ,;,,.,. "•<''-i...itlK.san,..,,.i,...i- 


"";' "'." ""  "'"><■  tii=i>  oi„,.,i„  i„  ,i„.  „,,,(„„ 


lit  "1    ty,,l„,i,|   (i.v,.r.ill.|  th.. 


^.^^^  —  .„,    .1,..  van„„s  .„.n,,.,ns  an.l    Mu...|KM,i>n,.  „r  .iig..- 

"'"^"■- •'"■  •'"■•  -'""'I' M>ist  ,.x..|,Mv,.iv  „r  li,,„i,|. 

OCall    (;H,.l..,„ilki>   ,1,..  „„,.  ,1,„   •„„,.,    „..rly  fuDill.   ,|,„   ,,,,„i,„. 
...■ii.>ii.   tlu.num..,,fsn,.plvin..ll.„nnM.,.H,,,l,,,l,.:,,....,,.|    ,|,!  „„, 


II    i~  t.i  Im'  ivtrrctt.^l  tliat    a    la?.r. 


til.'   tM.ril,.   |),.ri.H|,  aiv    iinal.l..   t.i  tak 


V    imi.mImt  „|-  ,,a,i,,,„,  ,.s,„,.iallv  ,l„riii,r 


'■    ".  ii'    liii-I    ill  iiiiiri.K|i(i„|   f,,,. 


I-    I"';.-'-     ^'-.M    ,„„.    l,„„..v..,,    ,„„u    l,i,„..,f   t.,    1,..  t.H.   ,.a.ii; 

'i-'''"'""  "t  -trMa..  ,„•  „(•..,„„.,„„,  salt  ,„ay  l„.  f;,„„.|  t..  anMUT       A  v.rv 

^""'   '•'"".  --'-"'■  'Hi^i^fr  tl,..   milk  wi,l,  ..,„iM„i,|   -ul.,;,„,,:   .,„.,, 

':.",-'",''";""   ''"■'"^'•^"■'•""-' ••    Ki'"i"nn..|,LaM.i  ,l„.    iik...  l„.,.a,M.   i, 

=."-l^.l,..l.,.,   m..an-  „r  ,„..v,.„,in.  ,1,..   fi.n„:„i.,„.  i„  ,„..  .„„„„.„    ..f 
'--     .^1.11.    ,l,a,    ln,..,.f;.,.,.    .,    „„„.|,    wi,l,    .ii.,„n„„.      An    ,.,,,'.llv 

'■""■""•    ''■•'■^''^'!'- '•  • --'    -■--    H-..    ii „..nnilk.      |.i..l, 

;;'-M---'-l,.:il.tal,l,..       A.ain.,l,..,,a,i..„r.„,.j..,.n,„...... 

':•■ '■"■'7;"' ;"■"' ':""^ iiii.iiUkfo,-„i,vi,„. ,. „..„.„,,,•.: 

;;!;';;; "'•''■  ""vpi,us  .i.,,  i, ....naiiy  ,„.,.,.-,.. ,..  ,„,,,,„., 

Ill-Ill.'.....   M,av,., ,,..... ,il,,.,|,., ,1,1  ,,,,,.,,;,,  ,^.|,,.^_^,,,,,    ^^._^^.^,  ^^^.^^^^ 


<il)tairi.Hl  v.rv  t;iv..rahl..  iv^iil 
»>(   tlif  r(s|iimt(iry  |iassif:L's 


1-  li-nn     In-  uli,.,,  il„.,.,.  wa-  intcn...  ..atani 


\r|l 


■|-:il 


il:i 


If  til.-  hiilk  i-  «,.||  1 


l<lllli\lll|-c  (if  IT, 


ri'nin. 


r/!/:.\TMi:\r. 


""■"'■'  't    I'l^i.v  VMih  M.lv:Hira-c  iMTiirirl 


«ii; 


A 


I'.-irt  In. Ill  milk,  d,, 


III  a  lliiii 


"nil,  i'S|irci; 


"""'    "-"'"I    ''""I-  Miv  tli.  r,-M-|„,hv,i 


ilK  ;i>  rliK 


"""  "i'l'  'li''  tivatiii,.,,!  ,,f  tv|,|i,,i,| 

palatiilil 

\ai 


lip--       A-  ll;|~ 


ltd    i,\   ail 


rale-,  o-n,.,, 


I'liMiil  tc\cr,' 
<■  tMi-anv  l,.|i;.t|i  ,,)■  ,i|,„.  ,1,,.   ,„|,,, 


'"■III  -ai.l   III  I'oiii 


111  order  to  ivikI 


'i'  -ii'li  a  dii  t 


|''<I.      <  )aliiical,   rice,    i] 


illiee>  ii~e(|    niiiM    ( 


iriiia.  -a' 


Mat  t\< 


""•  'ilM.v  \<r  ilM.I   I.,  I.ivak  (he  Mi,,|„„, 


MVeii    wheat,  ta 


re(|llentl\    lie 


|ii"ea.  ami    aleiim- 


'llinilj,r    the    hei-hr  of    the    H-ver    >,iii 


IIV  "f   the  li.|iii,|  ,h'el.        I-: 


'•"■Iter,  >(,ii|,<  |,iv|.are,|  uiih   II 


I'-   '■oiitaiiiiiiij   evapuraii.l    (Viiil-  .„• 


irteli-telli  .-.   le.riimiii, 


t  i>  uell  III  alli 


-e,  liiav  he 


or  we  may  ailij   I,,.|ilie-K 


■Male  llie  iliii-k 


•■liii'kcii,  or  iiiir 


i'litiiar; 


'i|»  Willi  el, -Ml-   |,n,t| 


|«riiiitte<|. 


• ;   Ihi.-'  mav  he  ,1,11 


liieal-siiliiii, 


111.  >\M'et-lireai|s. 


le  iliiniiL'  an 


I     eulltailim^r     j.j,j_rj, 

lalve.s-lii-iiiii.M 


It    -hnlllil     I 


a;:e  of  ty)iluis  tt-ver. 


'<•    'll>till<tl\     llll.lelstud.l     (I 


I'lilc,  liy  tyjihii.   |)atieiil<  than    I 


lat    eii-. 


iiv   ! 


litter    I 


A^ 


many  as  three  ,ir  flm 


>y  patient-  -iiirerinir 


"Tile,  as  a 


•■lllier    s|i,|v,|    ii,  with    tl 


'•  <j:j:s  niav  he  taki 


iioiii  lyphdid  to\er. 


I'eateii  ii|.  uith  a  -iiiall  <,i 


le    -,,i,,,_tlie    Ix-t    liiethiMl- 


'•II    .11   tile  twelitv-tlmr    I 


loiiiv 


IKlir) 


jiiaiitltv  III'  I 


"iilllldii,  -weet  wine. 


soft    liiiileii,    or 
or  (•(i(i|i;ie  (eirii-. 


It 

kiiiils  (if  artilicial   all 


•■iisteiiiary  at  the  pn^eiil  d; 


ly  til  eiiricli  il 


Miitni.s(.,    en, .as 


111.    meal    ik 


iiiiMiiiuns  t'lioiis  ami 


a;  simps  hy  th,.  ad.liii.in  of 


may  he  meiitioiicl    IJel 


|K'ptJ)iies,    and    va 


eoiiiliments.  siieli   as 


sdiiiatose. 


(•'iiitamiiiir  verv  litt 


iel)i;rs  cxtrart   aii.l  Val 


nous   meat   extracts,  aiimiii:  wliicj 


e  alliiiiiim. 


eiitiiics    mi.at    jiii,',..  tiie    ] 


I 
itter 


On    the  wliiile,   [    |,r,.t;,r    j 


ineat-exli-ai-t.s.  ai 

hy  the  dise!i.sf  that  il 


'"■'■flea    |ir,.|,areil    i„    ,he    h 


lii'Ve  that    Ihr   pat 


odor   i)f 


'iiiTus  ranii.i 


ii'y  are  not  dlsirnst,.,!  hv  tl 


leiits  Willis,    .sensihil 


Mlse  to  the   arliliciii 


wineli  als aitaii 

should   h,.   „^,,,j   Cr 


/■"•''(/.<    r.rjiri' 


■/iri.^j<iis   I  \)^^^.^^ 


K'  appearaiico  and  m 


itics  are  .-,.  dulled 


extractives  of  meat   allmmj,,  j 


■JiiK'ei.  the    latter    nrepari 


iplea.saiit 


ition. 


II  a  very  diLrestihle  form. 


■fl 


le    Kurnin 


'■'!/•/(/.<    can    readilv    I 


Pitlier   III    the    lios|,ital    or   i 


>»■.  prepareil    with    K| 


s<-ioi,>  soiiietimes  take  to  it  quite  kiiidl 


11  a  private    1 se.      [>; 


and  .served  in  a 


rreeii  irhl.ss  to 


V  i(    It  is 


Itlelils  vvl 


em  s    meat    ]ire.« 


a>   are    fiiHv 


I' 


.'iiise  the  hidod 


im.xeij  with  wine  or   h,niilli 


V  color. 


llleilts  ill 


lll.l\-   lie 


^■'""1  mental  cunditioii  who  are  aid. 


allou...!  -iili.l  i;„„|    j,|  ^1^1 


to  .•h.'u  an. I  - 


any  -ia-.>  ,if  the   .1 
mav    I 


<liti.iii  t.i  til 


wallow 


l-ea- 


•'.  '-v.-n    ihiriiiu    ih. 


"■   jriv..,,    roll-,    Xwi,.|ia,.k.    .ak, 


I'  iiipiid  [>iv|iai-ati.ins  .Im 
lieiirllt    .if  the    tl'Ver.       T 


-prill;.-  .Iiickeii, 


Tl 


'|i'''l',  ;in<l  th..  lik 


pITl 


laps   i-aw  >li.i|i|M..I   II 


leal. 


K'   treiienil    rill. 


iioiirs,  a 

ihelll     t 


litt 


'■  ■"  ■•'  "111..,  ami  to  .■ml.av.-r  I. 


pati.'iits   ivui-iilarlv 


(."mI  t\ 


o   .-at   when    tl 
tl 


ly  all  iMissi 


everv  t\\,i   to    thr... 
d 


lev  are   stn 


jHiniiis.       I'ati..iit 


[Hissilile  iiiejiiis  t.i  in. hi 


""  '"•  tlinv  tim,.>  .Inri.ij:  tli,.   ni.rht— i 


ee 


r.'.'.ive    s.iiii. 


or  .■\ample,  milk,  l 


"iinlloii 


|i.  li'i: 


il 


■  u.  a. 


(ils 


Tvntis  ii:\i:i; 


-Wfl! 


y.i^-, 


;";'"""""'''"■'"-•  ''--ii"-'ii-.i„.n,.,n„.iini,.  ,.,..,....1 „, 

'■'";;"    ""■'''  —  " ■    ""-:i'llv    n,    ,...-, ,„|    ,1,,-,.,.   ,„,    ,,,„    i. 

'"-I-  -„„.„..   'Ih    |u,„.n,--l,„„|,|,,„,i,„,|,„|^,^„,.„^.„|^_,,   ._^^^^,_ 

,n,u..      C.l.l,.      ,,!,,:        ■""■"''";•   "'-   l"■-i^-l"i.l,..o.MM,.,„■ 
><ihh,!,i  I,..  i,.,.,i. ,„.  „  I .  '  ],| "     ,";•.  I :-■.•.■,•....>;  „,..„„„„..,i.  All  ,i,.i„ks 


\  iili  pi(>|„r  ,-,.,,-,..  ,|„.  „„,iill,',i„,| 


.-.■„,„,i,',„.-iv  '1,:;,;       ""'  '"■'"""•  '''■>•  ^'■"'- '"  <•""-.  "-y  >l,„„l,l  I,..  I.,,,,, 

li.i.-^  Im.,.,,  ;,|„„„t  ni,iv,.,-...|ilv  :il,ai„lo„,.,i. 

".  „..„„„i,,,„i,i  ,,,.„,„,,  „„„  ,v  „.,,,•„,„,,,„,,  ,,,,.,„,^^.„ 

^:;';  ••;""'";""  ;"■'■" ^'-•■•"•--•"^-.-.•■•-...i  ...■....„:.,..  t 

li«...  iiM.  i„a.\    Im.  tli<.  inraii>  ,.v..„  ,,r  -aviiitr  lifi'. 

It  i-  -.■a,v,.lv  „,..,...,,y  ,„  „„.„n,„.    ,i:,al,..vv.l,.i„|..,..„ ,„,,., 

'':":"•■'"""■"-•"' """--^Hia,- ,.>,..„•:.,„ n„..an, „. ,,■.„!,.;, 


N  a.ln,,M,.rn,„„„   „,n.n  I,,,  ,,,„,.  ^ I  '«';.,,  ni„.„  ,1„.  ,,„i.,„,  ;,  ,„.,: 

--Hi   ..a,„,„r  ,,„,,(,,.    i, ,|„„.,i„„l,.aual    n,„    i„nv,,u.„„v 

""'"'■^ ";;'""', ''"'"■ —i '"iHT  .v..,.,. -,,„,„,„„..  Ti,....  ,a,i,.„;. 

;;: •: ;:  f-  '^t ' "' •  ^' "'•  '■'■  '-■■  -"-'---'> 

'""    "I   :i   K""'!   .|imlily,   (.>|„.,.iallv    I'lN,,..,- 

r.,allvwi,l,    ,!„.   l...,i„„i„^„r,|,,i,,.,„ „....,  an<l  ah,,.,-,    ,...„„|..,.|, 

--  .-n,,„.„v,.     Si,,..,.  ,w  „,,  , „„.,,,„,,,,,::„„„„'  j;, 

"'"":'":' •-'"'M''-"-.,..  ,!„.,.,.  i,„„„,,i,„„,„, ,.^.,„^, 

":,':"""' ^  ^!i;'-'"-  '-^  ^'""-"^  i ~^n,iii,,„i,i  .,„,  .„n,  ,„,:,':; 

ri " ',:-'"■-"'    "-." -.t;n.i„a,,.,a.,;.,,         .         ' 


Tia.AIM/Wr. 


fill* 


'•v.'.ptiMii    ,,(•  :,,rhl,-    uhi.li 

liiiMlcr;ilc  riiviirii«l:iiic,-  u||c 
niu.lc  ,,|'  lit; 


-|i<'<i:iily    illtli,  III 


I     to    ilii 


IN    I-   a 


.1    pi 


I'lMii,    (-I,, 


iiiii-t  iviiini  I,,  il 


'■-'.    iriny    Im' 
'!■    I"  r-oii,    ill 


\Miliin  ;i  >li.,ri  (ill 


"■I''  ""i-lv  and  tlhir  C 


iriiirr 


ti>«;n 


klll'illi:    tlic    -|i,.|-ia|     „ 
•'I  I'oinliariii^r  t|||.  i;.|, 


iiIIjimI-    ,,|'  tlvaliiKiii,    tl 


called  antipyretic  methods 

'Hlr  Ihrt   liial    |||,.-,.  mhiIlmK   | 


liili'iMii    and    it~ 


"•.iiMii:  oil  iv|.|iii-  j;.v,.|-  i. 


iikI  tlic  Ilia 


i\Mlli, 


>"  tliar  lie   Iia~ 


ly  ilciMaiid-  on  ill,.  ,|| 


■rl||,v     til 

i:i\<'  not  licrii 
j)i'ol>;il 


i"~i'    Unit    a 
i'on~,-,|i||.||,.| ii 


lilK'tcl 


I'    so- 


<ii-cn-. 


|ilacc. 
'■'I  ill  iliiail  in  il 


'IV,    to    t 


i.'i-  nciiliiT  ill 


'I""-      A-  a  niic,  I 


jiliy-Kiaii  III  tiiiio  of  ex 
'■  "|>|"Ttnnity  n,,r  i|„,  ,i„„,  , 


!<-•  -Teat    jirc.^ 


uorl 


''■ii~i\i'  iiiid 


or  car 


'""'■vrr,    |||,„t 


•(111 


|llll(|||lCS, 

ol)>crv;i- 


inctliod-.. 


I    I 


<-|"  riallv  on  ||\,| 


roi 


!'''•' -"•'•'"-   |.l;i.vinn,lMvlianr,.,,i,||,,„ 


i:i\c  a  In 


liinipy  and  tl 


l(>C 


renewed 


~||"Ken   of   tlir    inidolll.tcd 


c  n-i'  of  ant 


i|>yretir  drii 


e|iideniiis  tl 


'"'  '"   ""iiI'Mlini:  llie  (i'V,.!-.      It  i-  ,,,  I 


!<■  i'|icii-air  tnainieiii 


'"'■  "'    'Ve-h,  (iv,|ii,,niK 
'"■  'i"|'<'<l    thai    in    Cut 


-nit;i 


I 


will     II,.    ,11,, I 


lire 


tin  nieiiiiid  t. 


e  e\tcii-i\-,.|v 


"|"'ii    air  even 
|if')|)er   |irotect 


-o  far 


eni|p|oyed    ill 


;i>  to 


iMiiiiiir   til,,   nij, 
ion. 


j'lovidinii'  tlieiii,   <(( 


e|)  tile  patients  in 


the 


••"iirse,   with    th. 


Ai 


•  ii">t   iii(ii> 


""-';r  >Ik.  vMrioM.  „.,,.  „,•  hydrotherapy 


tl 


'-i"n-;'l,!e  methods  are   I 


le  ll>e  of  tin 
I 


"ater  inattn 


.  til.'   Mni|i!i'-.t    and    the 
•athin;:,  |,„,,|   a|.,,li,ati,,ii,,|-,.„|,i,  ;„„, 


II    S'ver 


e   (■ax- 


patient  on  a  water-l.ed  tn 


I-  lias   IxH.n   stated    eUeul 


I'lil  the  l(e.ri,| 


"■|'<',    It     IS     l„.st 


'"    '••'H|.erainre    may  l„.   .till    thrtl 

-'■veral   Ihnes  a  day,  a  |.r.«-,dnre   tli 

''"•nn-  the    patient's    po.iti.m.      Tl 


'i'l 


to  put  the 


ler    I 


iiereased    |,v  ,\ 


iiKehanieal    niliiet 


lailuliijr     th 


"    ean    easily   1 


IS 


X'  carried  out 


ion 
e  wat<T 
\\ithoiit 


I. 


I): 


'"  -"     <••      X..  a. I 


"•  "-'t.r  shoiil.l    „„t   |„.  ,,,!,,,,,.  ,, 


wer  tem|(ii-atiire,  or 


vantajre   is    siviind    fn.in    tl 


laii 


i;ertain  to  <li>t 


even  ie(K|  w 


111  all  s- 


I'ess  the  patient. 


"•■r,  ;is  has  1 


K'    use  of  water  of  a 
'een  reeommeii(l(il,  and  it 


evere  leases  an 


•irinniiicr  and  dnrin.r  tl 


"•'-'•••W  >l'-'iild  he  pia,v.|  u„  th..  head  f, 


"■'itahle.  the  ii>e 
tiirhaiiee  of  chan 


le  entire    M 


\y 


len    ther 


'"    Inciters  tnhes 


:iii,t:  .111(1  relillinir  tl 


'file    periiMl.        If  tl 


•"111  tl]( 
II'  patient  is  ven- 


di-ease, 
eap  and  tl 


<'   IS   severe 


laelh 


leadaelK 


'  -inall  pi||,,„-  filial  „.i,|,  j,.^^, 


»_  I'lvieral.Ie,  for  they  avoid  the  di 
le  iee-eap. 
'speeiallv  ill    th(!    1) 


rn'miiiifr  ,,f  ,1,, 


"liieh  is  often  V 


":"■'"■'•  """"■•■>^^i>-«Telialde  means! 


^vater  is  valnaide.      l{,,t||  ,| 


'fy  t roil  1)1 


esonie. 


"f  '■"iiiliatiii),rtlieii|., 


le  lee- 

iiiinia, 


III    lee-l 


)a.<r   may  oft,.,,  „ith   ad 


''"-'""•  •■^l'<^'ially  when   the   p,i| 
'"■art    Ixyiiis  to  fail. 


jiiilse  IS  v( 


vanta-e    !>,.  applied 


to  tl 


p  !•(•(■(,  I'd  ia  I 


'■ijiid  and    irre<r„|ar  and 


the 


m 

m 


III 


iih 


liJd 


/ 1  rill  s  ii:vi:i: 


Kviiy  [.:iii,.|it  -hi'il!'!    Im'   I  Iii.iiiiil:1iI\    -.pnii-nl    tw ■    llnvi     liim-    a 

'l;i\.        I  111'  ]ir:iriic,'   ,,\'    I'lvmli  |ili\ -ii-i.iii-  111'  ihldin'^    ,i    little  \  itici;:i|-    to 

lllr    walcf    will     ..('till     111'     liillllij     i;l:ili'tlll.         rmirl-     c'cflaill     rilVlllll-tiltlcc- 

paitial    lit-    total    \Ml-|iaik-    trjav    In-    .tM|iliivi(|    aflrf    tlir    -|m  niMinn.       In 
many  la-c-  it   iiia\    lie  ai|\  i-aMc  in  n-r   tlnin    in    ^<\:u■,■   nf  ih,     -|.iitii;itii:, 

liiit  tlii\    inn-i  lie  .•arrtiilly  ivunlalccj  hi  -nil   imiix  idnal  < lilinii-  in  ilic 

iiiallrf  111'  l(in|M faiiirc,  (Jni-aiiun.  and  cxiini  nf  UmK  — in-tiicc  in  wliidi 
liitx    arc   a|i|iliril. 

Ill  iiiiiii>    |ulicni-  a  ( I  i.f  Inkcuann  uc'i-|iark    a|>|iliid  to  tlir  irnnk 

ainlliivM  !■  (All!  niilir-  (liirinL;  llic  lir-l  half  nl' llic  ni;:lii  i-  -m  11  —  111!  in 
allaviiiL:  ii'-llr-~iii—  and  indiicin;^-  -lc<|i. 

.\-  a  rnlr.  i.nr  -Imnld  ;:Mafd  auain-l  iIh'  Iimi  t'rc|ni'nl  n-c  nl'  vcrv  cnid 
|ia(k-.  a-  llicy  liavr  an  inidr-ifalilc  lA.'itiiiM-  cll'ivt  mi  nianv    |)ali(tits. 

Treatment  by  Baths — Aliliun-li  .ipiniiin-  nia\  .iitlcr  a- to  tlic 
niiinliii-  iil'iiiiil  of  Inkcwaim  lialli-  llial  il  i~  di-ii-aliic  to  ('iniiiov  ,  ami  a- 
lo  thr  way  in  wliidi  tiny  a<l,  no  one  will  i|cn\-  the  \aln<'  ot'  rin|ilii\inj: 
tliiin    \'\>-i\\    in    ly|ilin-    t'cscr. 

I  liavc  Ioiil;-  Ihid  llii'  ii|pinion.  wliidi  |  lind  a^r^'c-  with  that  of  the 
majoiily  of  |ihy-iciati-  at  thr  |ii(-cni  time,  that  tiic  |ii-in(i|ial  olijcct  aiincil 
al  and  thr  \aliii'  of'  the  liath  liratnicni  lie  not  -o  niiiili  in  the  i-cdiictjon 
of  tlic  lcin|irfaliir('  a-  in  the  faxoralilc  cll'cct  pfodnrrd  on  tiic  cntifc 
-ym|ptoin-c'om|)!(\  of  thr  fivci-.  |iaftiriilai'ly  on  ccilain  \ilai  ccntcf-  that 
aiv  (-jicrially  im|ili(atcd — namely,  the  fc- pi  fa  lory  ami  ciivnlatofN  cfntcis. 
'I'lic  tfiilh  of  tin-  a|>|icai'-  more  tiifciiily  in  typhn-  I'evrf  than  in  anv 
olhrf  t'elnili'  di-ea-e.  W'hcfea-  I  frci|m'nll\  (ili-ef\cd  an  excfedin^^K- 
-li'^lit  and  vciy  li'm|>onify  inllnencc  mi  the  lein|ief;itiife,  the  etlcH't  of  tiic 
liath-  on  till'  (M'feliral  finietimi-  and  on  the  fi'-|iifatof\  and  rifcniatofv 
ofMan- \\a-  al\\a\-  -o  mafkcd  ami  |icisi-i(iit  that  i  do  not  IicIIcnc  lv|iiiiis 
le\ii-ean  |io--ilily  lie  tfi'atc<l  withont  ffe(|iiinl   firiilaf  hath>. 

The  iiieiliod  to  lie  |inf-ne(|  in  the  lialh  Iffalinriii  niii>t  lie  >tficll\' 
fi'^iilaliil    areofdiiiM-  to  the  indi\  idiial    cii-e.        I    have   alfcaiK'  dealt   with 

tlii-    niithod  at    -onie  jeliLllll   in   the    -eetii 11   'r\|il|oi(l    j'l  \  ef.'    to   whii'li 

I  viWr  the  feadei'  tof  t'l  ifl  lii'f  d(  la  il-.  I  \\ill  onl\-  -ay  that  in  tviilin-,  a- 
in  ty|ilioid  fe\if.  I  iie\ef  n-c  cold  lialli-  e\ic|il  nndrf  -|ieei!il  eiiN'tim- 
>laiicr-,  ami  n-nally  pfcfef  /iiin— en'-  method  of  i;fadiiall\'  I'edilciiij;-  the 
tein|)e|-aliife  of  the  hath.  I  Jilaee  tile  patient  in  a  hatii  of  L' I  to  2i)  , 
and  ■ifadiially  cool  the  water  to  lin  or  IS",  rarelv  lower.  A  ■■old. 
damp  eloih  or  an  iee-eap  i-  applied  to  tiie  patient  -  head  (hiriiii!'  tiie  liatli. 

KxeepI     in    ea-e-   of    eMreiile    deliilil\iir   uitli   -mile    local    contfallldi- 

caiiiiiT  aH'cctimi  it  i-  a  L:ood  praetiee,  in  -tiipormi-  and  comatose  patient-, 

1    -;.■.•    T.l/J,.;,/    I--,',;,-.    |K    4-'l';. 


iSSi- 


tui.mmi.m: 


•;•_'! 


Ill  ^'■i\('  ;i  cold  (Iciiiclic  (i\ci-  the  lirad  mikI  trunk,  lilln  r:it  iiilci'N  ;il~  iliiiiii" 
llic  li.itli  i>r  al  llic  cimI  III'  the  lialli.  ALiaiii,  Imwivi  \\  \  n-c  c.lil  wale  r  or 
(•\rti  ircil  wall!' uiily  in  -[(ccial  <a>c~,  (■iiniintiiii:  rii\ -eh' u  itii  wali-f  at  a 

lcrii|>iratiirc    <>\'    IS    ,    L;ia>liially    ri'iliiccci    i,,    |ii    .    alll ^'li    utlici--,    ..n 

<  'nri'irV  i-ccciiinii('iiilaliiiii,  lia\"(  ail\  i-rd  llir  ii.-c  nl'  Icc-u airr  a>  a  iMiiliuc 
jiractiic'. 

'I'lii'  rn'i|niiM-y  ni'  lln'  liatli-    -limild  ili|iriiil  imt  alnr rrvcii  iliiclK- 

(HI  till'  lMiilv-li'ni|)iiMtiirr,  a-  I  iiiii-I  airaih  iiii|ilia-i/c,  Imt  un  tlic  Lr<'tii'i'al 
(■'iinlitiiiii,  ami  |iartiiiilarl\  nii  tlic  cuiiiliti'Mi  >i\'  tlic  cciilfal  imia  mi-  -\  -icin, 
tile  |p||Kf,  ami  till'  fi'-|iil'atici|i.  A-  tli(-c  -\  lll|itiiiii~  ai^'  liUiK'  to  lie  xp 
tiiMili  iiKirr  ip|)~liiialc  ami  -rvnc  in  l\|iliii-,  a  '^fiatir  iiiinil)»r  (if  lialii> 
will,  a>  a  fiilr,  lir  ncc(~-ai\'  than  in  t\|iliiiicl   tivrr. 

When  llic  t;icilitic~  arc  liinitiil,  a-  in  |ii'i\atc  |n-aiticc,  wluri'  it  i-  ni>t 
alway-;   |Ki»il)l('  in  j^ivc  a  full  Latli,  it  niav  lie   a<lvi-alilc  tn  n~c.  in-lcail, 

liikrw.inn    ami    i 1    -|«iiiL;i?iL;-   r.iMiliinril    will    i|cimi-|ic-.       I'li'-ciiialls     I 

liavc  \cry  little  lAiicrirnci'  in  rcijiii'd  to  llirir  cllicac'v,  Imt  on  nciicfal 
|)fii)ci|)I<'s  I  (hi  nut  liilicvc  tlwir  \alMr  can  lie  a-  jrrcat  a-  that  dt'  a  i(  jr- 
uliir  cdiiive  (if  liatliiiiL''. 

('(lid  (Idiiclies  in  an  erii|ity  liatli-tnli.  as  lii'~t  recnmniended  li\  (  in  rie 
and  after  him  cin|iliiycd  liy  many  [ihysicians.  xiiiie  nfwlidin  carried  it 
Id  an  imreasonalile  extent,  1  lielievc  to  lie  a  imicli  inferiur  methdd.  I 
cin|)ldy  it  only  in  cdnditions  df  (lecp  coma  and  >tu|idr,  (ir  deea-innallv  in 
marked  catalc]ilie  cdiiditidiis,  pruvidiii^r  they  are  imt  edm|ilicated  liv  a 
siihiidriiial  tem|)er,itiirc.  My  experience  is  stniiiirlv  UL'ilinst  the  ad\  isa- 
liility  (if  em|)ldyiiij;  it  in  cdiiditiuns  (if  marked  excitement. 

In  place  df  cdld  liatlis  llerniann,  lui  the  strene-tji  df  hi-  ex|)ericnces 
dnrinir  the  Pcterslmrir  epidemic  df  iSTIaiid  1  ST'i,  advdcatc-  the  use 
df  pnitraeted  lukewarm  liaias.  Ilis  ultimate  results — he  had  a  mor- 
tality (if   l<i.<i    per  cent. — are  not  verv  eiicimra^-inji;. 

Ill  a  few  instances  I  have  seen  favorahlc  results,  es]>e<'iallv  as  rcLnirds 
the  sedative  etfeet,  from  baths  df  this  kind  cdiiiliined  with  cdld  ('(impresses 
or  an  iec-liai^  tn  the  head.  I  should  advise  tliat  the  nietli(Ml  he  tested 
carefully  in  future  epidemics,  opeeially  as  certain  niddern  authors  in 
(Jermany  (iJiess,  I'liverridit.  and  Kichli(irst)  have  warmly  recdmnieiided 
it  in  the  treatment  df  tvphdid  lever. 

lu   a irdance  with    the    then    aeeeptc(l    principles   df  therapeutics    I 

made  a  very  extensive  n-e  (if  antipyretic  remedies  dnriiiLr  the  years 
fi-din  1S7(!  to  IHTS,  without,  however,  any  marked   result. 

Now  that  dpinidiis  dii  the  treatment  df  fever  have  niideryone  so 
marked  a  chanire,  and,  as  has  heeii  repeatediv  stated,  the  ad\antaL''e  o<" 
reduciiiir   the    temperaturi'   alone  is  accoiiiited   of  luucli    less   importance 


I 


t;:JJ 


/ 1  rill  ^  II  ill:. 


liP* 


than  I  M'liiriK.  I  ,iin  liK'liiici,  t<i  rii.iKi'  Inn  a  \iv\  liniilcKl  ii~i'  nl'  ~iirli 
riiiii  Wii -.  and  w.'iii.l  ii  .■•inini.  ml  ^Ti'ial  imic  in  llnir  -(licliciri.  I'lii- 
|iriiaiM  ion  i-  all  llii'niMiv  ik  ir--ai-_v  a-  l\  |ihn-  I'vi^r  |>alirnt~  -.wr  niiicli 
ni'MT  lialih  In  lie  ailarkiij  liv  -ntliliii  licarl-liiiliin'  lliari  an'  paliiiit^ 
-iilli  I'inL'  Irnni  l\  {>li'>ii|  I'.a  rv. 

'I'Im-  u-f  111'  -alir\  lir  ac  ill.  -Milinni  -alii\  laic,  kairin,  lliallin,  ami  anti- 
t'cliliii  -hnuM  I"  alianiloni'l  all"L:il  lie;  nn  aminnl  nl'  ihiir  niaikrd 
cll'ii't  on  llic  licai'l.  (.^iiinin,  anli|i\i-in,  iilnnaiclin.  nnl  lacl'i|i|ii  niii 
riiav  111'  ii-id  in  icrlain  i-a-c-.  accniilini:  In  llic  |ii'iii(i|ilr-  laid  dnuii  tor 
the  Ircatini'Ul  nt'  I\  plioiil   li\ .  i.' 

<>t'all    iIk-i-    ii  nirdii -.   Iart..|>|i('nin    i~   llir,.ni'   I   ar -t   iin-lincil    In 

ri'iiirnnhnd,  and  I  liaxc  i-iriinK  had  cnn-ii  Nralih'  i\|ii  rii  ncr  w  il  li  ii.  it 
i~  |irariically  wiilmnt  any  injiii'ion'  ctl'vcl  mi  tlic  luarl  and  n -|iiralion. 
and,  ill  adililioii  i.>  i;-  ni.irUcil  .•iiilipyiTtic  aclinn.  it  i~  c-iici'ialK  iix't'iil 
tiir   allayiiiLT   lAciliiiicliI ,    ilcliiinin,    and    iii-nnini,!. 

Oilier  rnni'dii-  li.ardK  innic  into  roii-idi  ration  in  an  ordinar\'  ca-c 
of  ty|iliii-  I'cMr,  In  |iri\ati-  |>racticc  and  liir  lio-|iiial  |i;iti(iit~  w  lio 
arr  t'oiKl  ot'  t.ikin^;  in.  (liciiii,  t  lie  ii-iial  liydrorliloric  acid  ini\liiiv  or  ;i 
dccociioii  ori|niniii  with    li\  ilrocliloric  acid  iii,i\    lie    |irc-crilicil. 


m 


TREATMENT   OF    SPEQAL   CONDITIONS   AND  ORGANIC 
CHANGES. 

In  ^pcakiii;^  of'  llic  (Vent-  and  condiiion-  tlial  inav  call  (or  cspocial 
till  ra|icin  ir    intervention  in  the    coiir-e   ot"  t\|(liii~  tc\  er    1    iiiav    inciitioii 

jiarticiilaily  weakness  of  the  circulation,  cardiac  and  vaso- 
motor palsy,  and  collapse  in  general. 

In  a  ili-ea~i^  wliicli  i>  relatively  -o  >liort  in  duration  and  ><>  severe  in 
it-  -yiii|itoin-.  where  the  cri-i-  may  li  e\|)ectcd  at  a  dctiiiite  jieriiHi,  the 
|)atiinr-  lite  may  de]Mnd  on  liceiiiniiiH- a  rational  ircatineiit  to  cuiiiliat 
iiii|Miidini:  eiilla|i-e  at  the  |iro]per  iiioineiit,  aii<l  j^radiiailv  iiiere;i>iiiir  it- 
tiirce.  MvirvthiiiL'  nia\'  dejicnd  on  kce|iin!.''  the  patient  alive  nntil 
the  tit'l(inth  or  -ivcnteciith  d.iy,  when  the  cri-i-  ami  a  -|Mintaiieoiis 
cli.an;/'e   till'  the    liett.r  mav   Kc  e\|icetcd. 

.\llhoii;_rh  -timiiLiliiiir  rciiiedie-  -hoiild  he  <trictlv  wiihhild  in  aiiv 
iliieoin|)lic,ited  ca-e,  tiny  -lioiild  he  em|iloyed  iinlie-itatinel\  to  tlu'ir 
f'nllc-t  extent  at  the  tir-t  -]'j:u  ot'  iiii|ieiidiiiL;-  tailiire  of  the  circnlatioii. 

A11101115  -tiiiiiilatiiiLr  remedies  tlic  lir-t  place  i-  accordeil  to  alcoholic 
lievci-i^c-,  althoiiLrh  their  manner  of  .action  tiinv  not  lie(|iiite  tiillv  niider- 
-lood.  At  the  lir-t  -i^ii  of  weakiii--,  old  liliinc  w  iiie,  I'ordcanx,  or 
liiii'ii-iindy,  aceordiii',^-  to  the  individnal'-  circiiin-l;iiice<,  -iioiild  lie  Lrivcii  ; 

'    ■r„,.l,.:,.l    r-rrr.  |i.  4t.l, 


*      I 


}. 


1 1: 1  1 1  \ii:\r. 


><S.', 


il    iiiMn-   :irii\r    >liiiiiil:inl-    ;iiv    iii|iiirri|,    |„.ii.    |i,:iv\    1 1  ii  mmi  i:iii   wit,,-, 

-li.iiv,  ..I-   ,  |,;,i,i|Mi:iic.        I':iliriil-    ..fill,.    I vr    .1,1-,-    hi.iy    !„■    -i\,.|i 

l(r;iii.l\,  I  illiir  «illi  ,.r  «illi..iil  ual,  r.  1 1'  .■\aii..-i-  i-  in. -,  ni.  :iii,|  ili,. 
(■\l|-iiiiili,-  :iri.  I',. I, I  and  llic  l(iii|M'iai  iir,.  i~  -iil.h..i'iiial  •  ,  tin-  |iall,iit  U  in 
.■.•lla|.-..,  ::i-,,:.',  immII,,!  uiii.^.  ,,r  ,.,-nac  in  -lr.,ii^r  |,h„.|,  ^,,|i;,,,  ,,,.  ,,..j  i,,.,^. 
lie  ii-,',|   H  ilh  a.l\  anlai,'.-. 

I    |.arli,-iil:irlv   iv,-,,i ,„,|    ||„.    „-.•    ..f  al...l...|    in    ih,.    Inriii  ..|'   ll„.  u.ll- 

kiLiuii  S|  ikes'  iiiixlur,..  ..n  a,v..iiiil  ..I'lli,.  .-a.-c  wiiii  «lii.li  ilu'  .!..-,■  nia\  l„- 
rci."-.I'ilc.|.  ;ui.|  lM■.■Mll^,■,  ii.iiiL'  ill  ill.'  r.irni  ..f  a  iiic.li.'nii'.  il  piiiu  lie  L''iv,ii 
^illi'Ml  III,,  paliciil'.-  kii.iwjiML'c.  Til,,  loriiiiita  in  n-,.  in  niv  '.•lini.-  i>  a.-, 
t'.illnus  : 


K.      Spiril    \  in    i-.ii;nac, 


•  lOn  : 

N..    I  : 

Svr.  I  iiiiiiiiii.iiii,.  J.-,  ,, , 

A.|U.   .1.-1  .  i;,,,,, 

•M       >i-'       ">i r  iw..  i;il.l...|„.,,ii|'ii|.  .v.ri   tvv..  Ih.iir- 

<  )i'ra-i.i|ially  I  ailil  tiiicl.  vajii'.  alliir.,  .l.n  t.i  ."i.n,  a-  : rvc  L.tij...      IT  ih,. 

|p,iliriil    ,.aiin(it    ••\\all..u   ..r  ali-oliii,.|y  nln-,-.  t.,  take   .■•l,...|i..|,  it    iiia\    I.,. 
ailinini-lcivd  in  a  iiiitriliv,.  cncina  ..('  lli<.  f,ili,,\vinir  t'..riniila  : 


B-      ."^I'liit,  \  ill.    c  ..-nil.-,  .(,11, . 

Tiii.t.  val..r    iilh.T.,  .-,  ,(  . 

Vi|..ll    ..X   .  N...   I  : 

Mile.  ;.niiii  iiriil...  2n.<i  ■ 

■^'I'l"  .|,  -.  11.1     l^n.n. 

M.     SJl;.     'I'..  I...  ;.'iv..ii  us  ciii'iim  an. I  r..|i."itf.l  ihr...  lim.-. 

To  c.inliat  tlii',..,lia|(M^I  |H(t'cr  <ami.li,pr  t.Matriin.  Mntli  arc  aiiinin- 
i>t(iv(l  .■xrlnsivciy  in  tli..  r,,rin  of"  liy|.iMl.iini,-  inj,..ll,in~,  catfcin  in 
the  fliiin  (iCatllin.  iiatr.  siliivl.,  ,,ii  accimnt  .if  tlic  ^ivaicr  MilnJ.iJitv  in 
tlii>  ti>i'in. 

I  iicvir  u-..  iiy|),i,l,.rnii,-  iiii,.,.ti,ii,.  ,,f'  (tlicr,  a-  llicy  aiv  ncitluT  >,i 
<|iii(k  ii.ir  >,,  la-lintr  in  tin  ir  ctrrct- a-  .•ainiilinr.  ami  aiv.  l)(-i,l,.s,  very 
|)anilnl  and  th..|ii,.|itly  pnninr,.  al)>c,.~~,'s  and  ikcimh^  ,,1' tli,.  fattv  li— iic^. 

For  111,.  liy|Ki,l,.rniic  inic,  i  ,i,  nf  ,.aiM|,h,.r  a  frolilv  iir,.|ian.,l  .-..ilnlii.n 
IS  I.,  lie  i.n.ffj-n.l  l,i  th,.  ,,ffi,.ial  caniiiJM.r  nil  f..uii.l  in  ih,.  >i„ivs.  I  ii.>,.  a 
.«tr.Mi_'  an. I  a  weak  s.ilnli.in,  a.' •ilin.;  to  llic   t'.inniila-  : 


R.     ('iiiii|ili..r.  irit.. 

.Kill     Mlljlll.. 

I II.  .iliv.  pari-s.. 
<  >r  a.-  .~.iliiii.i  ..ainplinri  tiirlin?  : 

IJ.      ('Mliipli.  trit., 

HI.  ,.liv.   piil-I»>., 


1  O: 
-.0  , 

K.n. 


l.O; 
■'i.O. 


w 


'~1.U' 


i;j  J 


/  1  /■///>    /  /  177.' 


V—  -     f 


[?T-i- 


't  ;■  ■ ! ' 
♦•    -  -  i 


ll  llif  ii-f  mI'  i':iiii|ilii>r  lin.-i  l)ri  ii  ilft'itltil  upnii.  ii  -li.MiM  lif  L'ivcii  in  ;.'iii. 
(■riMi«  .I..-I -.  (Ill,  ,,!•  m.i  -\  niiL'i  I'mI-  nf  tin-  uiMkir  -•ilulinn  iii:i\  !„■  -imh 
i\tr\  oiii  In  ihrif  li'iiii>.  :iii.|.  iiiiilcr  •  i-rlaiii  finiiimtiiiH  t  «.  tin-  -.iiiic  :iiiiiHinl 
"I"  ilii-  -iicin'ri-  iii:i\  I..  -iriiil:irl_v  uiliiiiiii-lricil.  Nn  ili.-a;.'ri'iMlili-  ii-ull> 
v.\\\     i.i-    I  \|.<ilrlirr.|,    :llhl     (III    cllcrl     |.    nt'lcli    i  \.  ii'<  llli^  I  \     l'imp.I. 

<  alliiii  I-  iiM  |r»  I  lliciii-iim-  ill, IN  i:iiji|.li..i-.  A-  \  ;i-niii..|i,r  |iar:il\ -i.-i 
|.r'.l,:il,|\  |il;n-;iii  i  In  |  ...I'lMlil  |i:irl  iii  llic  |ii'<>.|iii'|  imh  .,|  .mI  |:i|,-..  in  1\  |i|iiis 
ti\i'i.  M-  ll  ilm-  ill  nilur  inliciiiiii>  i||.r:i.-i-.  iMllciii. '■»  111::  |M  ll-  >|,i(ial  arhnii 
nil  llii-  \a-iini'p|nr  -v-iim,  i.  ut'iiii  I'muihI  i\i  n-nu-U    u-i  lul. 

W  ll.  11  lln-  pill-.'  i-  \c  \\  i:i|pii|,  inv^^iil  ir,  aiiil  \^^\\  in  liii-i.iii,  illL'ilali* 
i-  imlirih  ll  ;iimI  in,i\  |iim\c'  ii-i  liil.  IT,  Ihiwcm  r,  ||i,'  .-.iHaii-c-  rMiiiinnr-, 
il    i-  III  II,  I    |..  -nl.-iiiiiti    r.illl  in. 

I  lli-r    1 11  Ml  I  ■(In  IT-    -llMllM.  Ill'  ri.nl-n,  I  ii  ■   i  unil  li  IK  1 1   W  il  ll  ol  IllT,  f-]iciia  II V 

|ili_\ -il  al,     iiiitliiMl-    i,r    In  .tl  III,  III,    lilliii     r,„.liiM_'     a|i|ilii'a(iiiii a-,    liir 

i\aill|ilr,  llir  iiv-liii"  Im  iIii  lirail  i.p  llir  |  ir.i  ••  Hi  li.i ,  ailil  lllf  ll-t'  111"  the 
walir  inalllT--,  \xiili  ..r  uitlmni  rliaiii.'iiii.'  llir  «  alir,  anil  iikiI  -|ii.iit.'in).'' — 
iir  llif  a|i|ili('aliiiii  nl'  waiinlli.  In  iiii|iiiiiliiii:  liiirl-tailiiri'  mlil  circvcll 
liiki'Uarin  li.iili-  mii-i  In-  n-nl  «iili  laniioii.  None  Inii  a  lii;.'iiic(|  I'anatii' 
nil  till-  -iilijiri  i.r  IimIi-iiiIic  ra|i_v  uill  (lrn\  ilial  iIhn  IcimI  In  liriiiLT  "" 
fiilla|i-c. 

N\  Inn  the  [piil-r  i-  llir.  ails ,  llic  triii|iiTaIiii'r  i-  -iilninniial,  ami  tln' 
lari'  aiiil  rMi'iiniiic-  ail'  i\  aiintir,  ininli  ijni.il  iiia\  lie  ai-i'iini|i|i-lic(l  liv 
tilliiiL'  tlir  water  iiialln--  uitli  w.iriii  \\atrr,  lis  a|i|(l\iii;x  Imt-watiT 
linllli-,  li\  \s  i-a|i|iiii;r  llir  cxtniiiilir-  in  flannel-,  ami  li\  the  a|)|ilieatiiiii 
III    I,(i!er"-   a)i|iai'alii ii-in^''    warm    water — In    tlie   prrenrilia. 

Nervous  Symptoms.  —  Ainnii;:  ntlier  m  Mi|itnin-  .ami  < iplieatiiiiis 

rn|llirinir  ,-|ieeial  treat  till  lit  tlm-e  alVceiiiiir  the  iiervnii-  >v-teni  oeeiipv 
tile    lir^t     plaee. 

rill  Mitnleralili  headache,  whieli  t'rei|llellll\  ileelare~  jtMir  at  till' 
lieiiinniiiLr  111'  till- di-^  -■■,  rti|iiiri  -  eiieri:etie  t  reatnieiit,  A  water  pillnw 
ainl  an  iee-eaji  >liiinlil  lir-t  lie  nnlered,  rnjlnwed  in  iiianv  eax's  hv  enlil 
ilniicliv-  til  the  lieiil.  The-e  may  lie  irivcii  aliiiii-t  without  ehan^'-iiiir  the 
patient",  pn-iiinii,  nierelv  li\-  Imjilin^r  lii..  ||,ail  n\  er  the  f(l;_'i'  'it'  the  IhhI 
ami  plaeiiiif  ;i  ve— el  miller  it. 

Manv  patient-  lliiil  emnpre— e-  nt'enlil  water,  til  which  i~  added  a 
little  \iiie;.'-ar,  alenlml.   nr   call  de   enlii;.''iie,  i^ratefiil.       Warm    euinpre,-se.-< 

are  -ninel  iine-   -iinthillL',   e-peeiallv    ill    iilil,  anemic,  nr  Verv    i'celile    |ierMill>. 

In  yiiiithl'nl,  pletlmric  imli\idnal>  iin  he-itatinii  ~liiiiilil  lie  felt  in 
ajiplyitiL'  arlitieial  Iceehe-  liehiml  each  ear  nr  In  the  tempunil  reirimi. 

Il  the-e  mea-iire-  Tail  In  relieve  the  headache,  .aiitipvrin,  pheiiacctin, 
and  l.i'-tnpheiiin  may  lie  le-nried  tn.  I'Aeii  npiale-,  e-p(eiill\-  hspii- 
dia'inie   iiijeetiun-  nt'  niiirphin  (i).(H    to  (LOlo    irni,   p<a'  do-e   in  adults), 


I  ui.ii  wii.m: 


«2' 


mav  Ih.  K'lv.n    vm,),,,,,,    ,i„     ,|„J,„ -t    iH-iiali.,,,    an.l    m.v   uft.n  .,1'  ^,,..at 
ll-c. 

Anu.h.T    ..iiulK     „„|-,-,:,„.     ,.„„„     ,„.|„„r,.     -,,..,.,.1    nva.in.nr 

i>  insomnia.     It  ihi-  ...niimu-  iiiiiiii,.ini|,...,ll\  \\,y  Mv.nd  Aas~   ir 

i.i;u    MMval,  M  rl„    |,ah.  ,„■-  111,  ,  an.l  i„  aiiv  Ma-,.  „|-  ,|„.  .||.,,.,,  ,,  ,,',;,J,„. 

••'''!'■  ^""""iil  •.!■  .iuimmI  -l,.,|..A,.n-a  n,ark,..|  ,.,„, ,|,,   ..,,,,,„.,, 

■vnl-r-.  «|,i,.|,  a,v  ,,t„„  -,,  |„-,,|;„„„IK    n.s,,K,,|,  ,,„l,  ,l„-,,n,,l,    ,1,.., „ 

llic  rntirc  ,',,iir-,.  ,,('  il,,.  ,li,,..|>,, 

^'"'"'    "l»"  ^"i-     nnl    l,;,,|i    ., ■..,., n,, II    j,    .■Miv„,..K    valiial.lr    aihl  ,,rt..|, 
^iilli,-,-  1,1  ,iv<r,' ■  ilu-  iii-,.iiiiiia. 

.    "'  ''"■  I''"''"'   '-  ■"■'"- "•<!  '"  III-'  MM.   „r  aln,li„l.  a    -mall    .|iianlilv 

"'    '"■'■'■•  '"I"!'"' •  tl„.   ,laik,.r  .  ,n..,i,.-    ..r    ,„,r„.r.  m  ^    v.,il.   a,!..,,,"- 

'•'-'■  '"•    -'""    '"    ''"•  'v.  iiin^..      S ,;.„    ,,ati,.n.-  aiv  i,ii,.v,.,l    |,v  l.n,- 


iiiid  ,ir  vaiii'laii.  ..r   th,.   luc 


l'"'.i~    Ml    <.,,|iiliiiialii,ii.       'I'll,,    iii-iiiiiiiia    a 


w<ll    a-  .1,,.   Ii,.a,l:irl„.  i.iav  .■,.,|iMn.  „,,iii,i,    „r   i„„|.|,|,iM,  an,]    tli-.s,^  .|n,„s 

''' ''  '"   -'^■'"  "nli..,iiatini:K.      I  .,,,,,,.1,.  ,,1,,,.,,  „.  ,.|,|,„,,|  „„  .,,. ^^^^ 

"'     ''"•   ""'^'^"'••il'l''   ''Hi...t    i(    ,.x,.n-   „i,    ,|„.   ,.i,.,.„iati,.n.      S,„„.  ..f  ,|u. 
'";;;'■'■  I'.M'".4i..-,  wl,i,.|,  |,av..  l,..,.,,  ,; I  „.  „„.,„|  i,.  vari„ii,  ,.,MHliti..„.. 

will    n.,|ll|r,.    ,..-|ll,ir    1,1     III,,,,,.    ,.,,i,|,,,„i,,    ,,,■    ,,|,|„,^    ,;,^^.|. 

1"  ''"■  'n.itui,-,,,  „f  ,!„.  delirium  liy,lr;„|i..,a|„.|„i,  ,„-,M...,|,in..    .„.,. 
;.i    -Ml-..    ,li,.  ,,,,,,,  Hli,:,i,,i,,.  a,i,|, I.,.,,.. Uli^il  II,,,  ,,i,,,  ,,,,,.  ,    „; 

""''/"'"^'l     l-'MllMI-Ki,.-,     Miav     „r,..,|     |.,„v,.,„     ,|„.    .„...||,,.,,„,.     „,•    ,■.,„,„ 
fXl'llflllclll. 

li:  l"'".v..r.  ill  .,,i„,  „,■  ,|,„i,  „„  ,.•,,,.,„  ..„•„,,„,,„  ^,,,,1  ,,^,,.^.^^__^ 
.l.v,.|„|..  iMlunaiiM    ,.a,.k-   ,„•    |,ik,.ua:n,    l,a,l,-    ,|,o„M    1...    „...,|   i„  ,,|.,i. 

!;,"";',""'"'''''""'' '■""     i"'-'-^   -■   <"M    .•o,M|„vs<...  ,.,  ,l„.   I„.a.i 

'   ",    '"'^';^";"'    1'^"'^^"     '-'I-   ^"v   ' rn.t;.nv.l  t..  ...,I.l   .1 .|.,s..r 

I'olil    tuli-li:il|i-. 

Th...lni.M„l„.  |„.,.r..r,...,l  i„  ...„„|„n„.  ,|,i.  svn.pt.,,,,  i,„.|„.|,.  1,,,,. 
'Mi-i.  va,.nan,ai„l  tl,..  opia,.-,  .v,.,,  „i„r,,|,iii.  I  an,  in  th..  lial.i,  :,f 
^"'"'-    '"• '   ^""'   "I'i'iin    ...ptli.T   in   tl.,.    i;,!!„uin.r   f,,,.,,,,,!,  . 


R.      S,.,|.  |,r,„„  . 

S|iir,   \  ill,  i.i;;  , 


A. 


jii.i'  iii.'i.tli., 


IDJi : 
I'll : 
III  II : 
q.  p.  'JiKi  II 


Till'   |i-\, 


V-}r\nr     inatiii,.,,!     i-    ,,r    tli,.    irr,.,.,,,,.,    i,,,, „„.,.,„,, 


'•'•I"'"""-       A  o,.„a,    ,i,„|    „,,,  ,|„|„,,„,   „„    ,1^,,  ,,_^^^^^^^,,.  ^  I 


.•itt,n,laiit-.      Til,.  i-.Mini  ami 


•  '    in    violent 


pliy~i,.iaii  ami 


liiii'ly  i|iii,t,  aiiil 


It-  imiii,.,|iai..  Mirr.iiin.liiiu-s  sli,iiil,|  l„.  nl,-,,- 


sli,iiil<l  !>,.  aliiiu,.,!  t,.  nini,.  ii,.,.|i'  tl 


1"  "11,.  I,ut  th,,-,.  uli,.-,.  pi.,.<,.ii,.,.  i.  al.s,,lni,.lv  r,.,|iii,-„| 


'<■  intunt.      H,. -li.iiM  not    l.c  spiiLn 


WK 


ill 
HI 


(i2t; 


T)  riirs  1 1  VF.i:. 


m  :■■ 


e^ 


^ii 


m 


%, 


w^ 


I"i  iiimc<'i>-;iril_v.  iiiid  I'circc  ~liiiiili|  m-xcr  ln' ii-cil  csccji!  in  cxti'iiit'  r;i»c?^. 
I'"iniiii(-~  .iinl  ;i  ciiiitiilciit  <l(iiii;iiiiir  >>ii  ihr  jmii  ot'  lii~  allrnil:iiil>  fii\f 
l!u'  ;rnaK-t  aniniint  nt'  <  n.-iiiiiM^ciiuiit  Im  ilir  |i,iiiiiil. 

If  ilcc|>  CO.aa  Mini  stupor  (ltv(l(i|i.  -tiniiilani-  ni:i\  lie  r(i|iiiiv(l. 
I'liilcr  -iicli  niiiililiiiii-  ci.lil  (|iiiirlir>  ill  a  liikruariii  lialli  nr  in  an  ciiiiiu 
lialli-tiili  may  nc  ii^cliil.  The  iiii|Hi|-Iuiii't'  nt'  cantiil  alliiilinn  to  tlic 
uriiiai'v  -rcrtliun,  ami  llir  tVi'c  ii-c  nl'  tlir  callictcr.  il'  nccc-sarv  tn 
ciiiiihat  i-ciiiiii:'.  and  ii\  irliiliiiL'^  ufllif  lihnldcr,  caiiiKit  lie  tnu  .-lriin>'lv 
iii.-i.-li'd    U|(ciii,    [lartiiiilarly    in    tlif    ca^c   nf  a    -tii|MiroiL-.    |iati(nt. 

'I'lic  vomiting  lliat  otVcn  airuiupanic-  llic  li(aila<li(  anil  i- cvidcntlv 
(if  ccrcliral  orii.'in  will  rc(|uiiv  the  ircatincnt  a|i|ini|iriat('  !ii  that  cdndi- 
liiiii.  Small  |iiiv(-  nt'  ici'  and  the  a|i|ilic  ition  of  tin  'ic-liai:  to  tlic 
e|iifra.-ti'i<'  rti:i,,n  will  lir  fumid  ,,f  \aliic.  I  liavc  (ificn  ulnaincd  izixA 
n^Milt-    frum    \\\>:    w-v   of  aipia    amy-dala'  amara'. 

T"  relieve  the  t loiihlex iine  hyperesthesia  < if  tile  -Kill  and  liliix'les 
and  the  iil)-tinate  pain-  in  the  linger-,  tm-,  and  xile-  nf  tin  feet,  whieli 
an    |iartieiilarly  eniniiKiii    diiriii;;    tiie   initial  -t.ii;e  and   ai^ain  dnriiiir  the 

jieriiid  dt' defei-ve-eeliee il  n|-  |iike\variii   I'l-ei— nit/  liaiidaucs  -liiillld  lie 

tlie<l.  If  driiir>  al'e  fe-nfted  \><,  .  lih.rufdfiii  liniiiieiit  or  meiitliol  -lioiild 
lie  prelert'ed,  the  latter  either  in  a  -olmion  of  iili\i>  oil  e  ■y\\i\\  I 
U'licve  to  lie  even  lietler,  ill  tilt;  liinii  ol' a  jia-te  : 

.\lll\l.  n.'i      ■_'.(!; 

\';i-i'liii.    pari--..  .",ii  (I, 

M.      Si;.' — Spii'Mil  Ihirkly  i'li  !\  pii'rc  el"  liiit  ,ui(l  ii|ipl\ 

Tlie  respiraiory  organs  may  rii|nire  ii-eatment   in  varimis  wtivs. 

'I'lle  !rieile-|  attention  -hoilld  lie  jiaid  to  the  eiinditioil  of  the  lliisc, 
the  na-o|)liaryii\.  and     he  larynx. 

Attendant-  -lioiild  he  in-trneied  to  |iay  speeial  attention  tu  the  ("ire 
of  the  uo-e  and  mouth.  I  rrij-aiioii  of  the  iio-e  with  ';ak  -alt  -oliitioii 
or  some  (li-int'eetin^-  -ointioii  niav  oeea-ioiialK    lie  iieei— ar\. 

I'"or  the  milder  alfeetion-  of  the  throat  and  larynx  the  ii-nal  Liirules 
are  (|iiite  a|i|iropriate.  I  i'  the  \..iee  he^in-  to  ehaiiue  and  hoar-eiios 
develo|i-,  tlie  irfeate-t  \  i^iilaiiee  i-  iieee--ar\.  TIk  er,.:,!  liahilitv  to 
se\cre  and  ripidly  iiroLnv— in^-  ehaniie-  in  the  lar\nx  in  t\  jihii-  fe\(r 
and  the  -llddeii  de\  elopmellt  ot'  edema  of  the  ulotti-.  often  leadinjr  to 
asphyxia,  niii-t  alw.iy-  lie  lioriie  in  mind.  I 'inler  -iieli  eireiim-tanees 
the  |iatient,  e-peeially  it'  he  i-  lllieoii-eioii-,  -lioiild  lie  watched  (lav  and 
niylil  liy  a  re-poii-ilile  Mersoii  to  ascertain  the  projier  moment  fin-  traciie- 

oieilV. 


p 


rnEMMHST. 


(327 


='"<!  rv,,,,,,-,.-  ,„,  .,,..,.ial  I>vat.n,.Mt.      It  i-  III.,  K   „,  |„.  (;,||„„,..l   l.v  hv,,.,- 

Mallr    .-onirc-tlo,,     oftlu.     luM-.,     W|,i,.|,     ,.v,,„     „„v     U.VM~i,,MMllv'|„.    pn- 

v,.ni.^  l,v  st.vn.r.lK.ni.,jr  ,1,,.  lu,.,-,  an.l   f,v,,,„..,tly  ..hanj:!,,.  ,i;,,    ...jf- ,„ 

ot    tllr  IIMtiint. 

Tl„.  digestive   organs   .1.,   ,„.,.  a-  a   n.l,,   n.,,,;,-,.   „,.,.„„.„,. 
\hnm,  tlu.   l„..,l„  of  ,l„.   .Ii-,.a-..  a,„l   .Inri,,,:  ,.„„val..s..,.M.-,.   ol.-tinat,. 
.•..n-.t,,..t„.,-  .„„,,iM„.s  ,.....,„.-  ai.,1  M.ay  1...  t.vat,,!  I.v  ....ans  .,f  ,.,.,.,natu 
-'"''"  alM|,„n,Mal    M,as~a,r,..  ami,  in  rnntfa.liMin.ti,,,,  t.,  tv,.h,.i,l  IIavp,  1,J 
Ilic  adiiiiiii^ti-atidii  nt'  catliai-tio.  '     " 

I>iMnl„.a    an,l    ,n,.t..,riM>,    raivlv    ,v.|„ir.    tlMrap.uti,.    it.t.Tvvntiu,, 

•' '"■""■^"'  '-  "^"^'">  ='  •""-'  '" >  >.vii.i.t..,M,  a.MJ,  wl„.„  it  i.  p,.e,,,,t 

:i"l  I'll Ill's  ai'c  \aliirlc~s. 

Tho  changes  in  the  skin  that  fn.pu.ntlv  .„..■,„■  ,l,„-i„,r  tl...  poHu,! 
■t   .•onval.-,vi„-,.  aiv  t..  1.,.  tnaf.l  .xa.tK  as  in  lvpl„,i,|  C.v,-,-. 

As  ,vj:anls  i|„.  .I..v,.!.,p,n,  .,t  .,f  l„.,l-..„v^.  tl„'.  jr.vat.M  uat.hfnhH..s 
1     iu...,.s>arv.    fur  ,|,..    patimts   a.v    n>M.,||y    pn.tnnn.llv    pn,.tn.t...l    an.l 

:"'"""'""r   '■' ""■  ''•■^'""!-'^-      '-'-'   "•a.v  is   .u.,.;..>a,-v  not  onlv  to 

l^-l.  .I,r  l.,W,ln,,  ,.|,.an  an.l  s.nooth,  JMit  al.o  to  M>l,i,.,.t  th/l.o.lv  to  ,.ar,.- 
'"'    ''^'.'l>-    '-       i"^"i""-       It    I.MS    l„.,.n    >|,ou„    hou-    ,,,M..klv    i|,„    mos, 

"""";'"'■/' "'="'"""^    lM-i->on..    wln,.|,    at   (i.-s,    arr   not'   noti-.-al-k. 

inuv  lU'vi'lop.  ' 

Hi.'  treatment  during  convalescence,   if  „o  ,o„,p!ic,,tio  ,s 
«lcv,.|op,  I.  >inipl,T  than  in  anv  uthcr  acute  intiviions  .lisoan. 

After   the  en.lof  the   felnile   period    tl,,.    pati..nt>,  a<  a  rnh.    .-(vovf 

'■'7  ';''"'">•'  ■' •'"■   l'l'v<i.iMn    i>   n.or,.  often  ealh.l   ,„  „,  rostral 

"'"'  Mill ish  than  to  em n^.. 

'■;'"'  ••'I'lxlit-'.  when   if   returns,  may  he  .ratili,.!  m  itho„t  anv  sp.H.i..l 

'T'"'"'' ^'  ■■'^  ''^'-  ^'''■"•"'>-  '"-"  ^1"'W"-      I   refer  the  trailer  to  t'he  liiree- 

tlolis  previously  i:iven  as  to  ili.t. 

-n,,.  nervon>  >y.ten,  ami  ti,e  hear,  eall  fl.r  niure  earefi.i  attention 
Mt  tni.  tnne  than  ilo  the  ili.eMive  or.ran.  I„  ,„anv  eonvale-een,  there 
's  M  |H.r>Me,„  nervoM-  irritahility  or  a  eo.ulition  of  depression,  with 
"'"■':'■''   ''""■'•      "'""    "*■  'I'"    '■'"•■H'-t   .•.ml    n.emorv.      Sneh    -omlitioiis 

'■;;'""'"■  ••'""      "■   ••"-•    -'"^    •'•'-' '-•on,   exertii,,,;     Too  „arlv   mental 

<'t'"t   or  ev,,„.n,ei,t,   whether   plea>nral.Ie  or   the   reverse,  are"  likelv  to 
retaril  r<.eo\,.rv. 

A  prolonged  period  of  rest  I.  neeessaty.  espeeiallv  if  after  delerve.- 

""":"'  "';■   '''''7  ' '"""-   -'-^  =""<  --'k-      r,„ler'.neh  iditions  the 

'"""'"  ''"'"'''  '"■  '^'1"  i '  '""il  tlH-  symptoms  have  improv,.!.  after 


er 
lin 


rif:  i 


-    'ffl 


I 


()-J.S 


Tvr'iirs  lEVF.n. 


wliicli  lie  ii;:iv  l)c  iillowcil  In  u'ct  up  fur  :in  lioiir  ;il  :i  time.  Auy  lU'irlcct 
inav  lead  t<i  -vii((i(ii'  and  ilinrtly  ciiilaiiircr  llic  |iaticiit"s  life. 

After  a  S.VC1V  attack  of  !y|.liM-  fcv.i-,  a  period  of  recuperation, 

lirntraitcil  aicnnliiiir  to  llic  individual's  feed-.,  -Iniuld  lie  in-i-tcd  ii|M)n 
hcfoi-c  allowiiii:-  lain  to  n-ilinc  lii-  u-iial  arlivily.  If  tlic  jialii  lit'-  cir- 
ciiiu-tanccs  |ierniit,  a  sojoiirn  in  a  soiitlicni  cliniatc,  in  tlic  innuiitain-, 
or  Ml  ihc  -ca-lioiT  niav  !»■  ]in--(rilM(l.  l-'oi-  iMmnr  palimi-  a  prciliiHi^rcl 
.-ta\  ill  ilu'  iio-iiital  o-  in  a  l•oIlvall'^(■(■llt'^  lionic  in  the  (•(unitry  is 
ailvisiildf. 


iis  i: 


:il 


mvti  V 


i  dt 


LITERATURE. 


.lacobus  de  I'urtil.us,  C'Diiinieiitur.  ud  Avitcnii.,  14!t8. 

FraM'atori,  Opcni  oiiiMiu.      l>e  cmituf;iniiilms  t-t  iiiorhis  contaRiosis.      Vcnot..  Ijoo. 
Mussii,  I)e  ffl.r.  jK-stil.  ciiin  petc.liiis.      Vciict.,  ir.-iti.      HuU.t's  Uibl.  uwd.  pract.  I. 
Andr.  Cinitiuli,  Ciniiinfiitar.  lir  I'csti-.      W'lict.,  l.J.Vi. 
I.i'liciiwald,  Cliroiiili  iilliT  diiikwiirdii;iri  Tolfn.      Nui-iiIkti;,   1»;I5. 
Huxliaiii,  Ol)sor\ .  dc  iii-rc  ct  iii(irl>is  epidi'iiiiii-.      l.<iridoii,  17.,l'. 
—   Kssay  on  Fi'vits,  Iliid  Kd       Liindoii,  17.'>7. 
Ha,-«Tii>lirl.  Ilistor.  rnrdi.'.  iiiurlii  r|,id..Miii-i  .■!.■,      \'iiKli't'.,  llr,H. 
Sli-;ii-k,  (llwrv.  iiii'd.  d.'  rricirlio  ,uii,  iKtrrliii-,      ( ■uri-nilii'.  ITW;. 
K.Mirirl.atiin.    llistnr.    iii..rl..   vnuUm.    amii    17!i:i,-t   17!i4:i  Kniiin.irallis  raptivis  Ciilm- 

liacitiiii  dilati.      Krlaiiticri.  17'.t';. 
Sclinf.T,   rcl,,.rda>  in  iirid  iiiii  l!,.:;,.i,-l,iK-^r  ] 7(i:i  l„.ns,li..|,d.>  Ncrvnilirl-cr.      Krlanuen 

I7IM-,,  -^      ' 

Cum,-,    .M.-,li,-„l    Itcports  on   tin-   KtlV.-t.  ,,|'  \V„|,.r  a-  a   U.-nu.K  in    Frvvr      l.ondoi- 

17!>7. 
.1.  Hartnumn.  Dct  anstcckMndc  Typliii>.      M,.,!    .lii-ui--.  /.,iiMiii;.  Nr,  4:,.  1H)7. 


A     I'r.    11,'ckiT.    I"c-1..T  dii-  NiTvciiti.O 


iiT.  Willi.,  in  liiT-lin    1«(I7  InrT-.litcn.      Krfti 


V.    llil,l..nlpian,l.    fclM.r  den   arisfckondw,   T-plm  .    ni'l.^t   .initr.'n    Winki-n   ziir    H,- 
wlirankunj;  .kJ.t  iranzlirlirn  Til-iniL' d(>r  Krii-MH^sl  und  nnliriT,.raiul.T.T  M,.n- 

>rh..nspu<-„..,i.      Wioii,  IHIO.      (A    1 k    In,-   it>  ii,„,.  rcnmrkahly  ,.l)j,.(.tiv,.,  an.l 

oven  t()-<la.v  -till  W(>11  wiirtli  rcadiiii;.) 

Wi'dcnii'ver,  ]),■  IVl.r.  pct.uliial.      (i..ttiin,r,.n.  ]H\->. 

llartinann.  Tl rir  (I,h  anstivkciuim  Tvplni~       Wion.  1812. 

Ua.-..ri,  Stni-ia  il.'lla  tVl.r.  pctivli.  di-  (i.Miova  1  7!i'.>-18(K).       Milan...  IHIH. 

llul'i'laiid,  (■.•l..r.li..  Krici;-p..»t.      li.Tlin.  1H14 

A.k.Trnann,  V,.n  d.T  Natiir.ios  an.stockcn,!i-n  Tvpliu^..      ll..i,l,.ll„.|y.   ihH. 

II. .rn.  KrfahninijL-ii  iil.or  dii.  anstcok.Midnn  N.Tvcn-  i.n.l  La/,arvtliti.'l...r      •'    .\„tl      Bpr 
lin,   IH14. 

\V..lrt-,    |{,.Mu.rkMni;..n    uL-r   dio    Kr.iMkl,..it..M,    w.l.lio    ini    .lalm.   IKIH    in    Wars.liau 
iM-rrsclifn.  l.,.s„nd,.rs  iil.,.r  .l.-i  an>t,..'k.'n,l.Mi  Tvpliu>.      H,if,.l.  .|.,„ni      1814 

K.Mianl.   H.'.trai:.. /.ur(J..>.l,i,l,|,.  ,1,.,.  IIirn..nI/.„r,di.n!:  und  dos  an.«t..<.k,.n.l..n'  Tvi.hus 
Hiif.l.  .I..iini.,  181.V  .  I        • 

KoM^>,   l,l..n.ilal  d.-s  Kl.vktl..l...rs  .nit  d.'f  ..rirnlal.  IVt.      Niinil.or!:,  18ir, 

Annstn.nt;,  A  I'm.-t.   Ill,i-tr.  ..f  Typhn-  V.v,;-.      I,.,n,l,,".  1819. 

K.  .Iai'ks„.i,  A  Sk.'t.'h  ,.)•  tl„.  Hist,,ry  ..f  (■,.ntai:i..iis  Klvt       l..,nd..n    1810 

llark-rand  Cl.oyn.r  An  .\,r,aint  ,.f  ((„■  hVv.T  Lal.'ly  Kpid-niind  in  Irolan.l.     I,..nd..n. 

Mar-li.   (.l,.,.rv.   .,n    .1,,.  ()rii;in   an.l    l,al.-nt    I'.tI .,f  r,-y,.r^.      I)„l,|i„    H,,,,,     «..„ 

lM-.'7.  V..1.  4.  II-' 

(•■■rri-an.  On  tlio  Kpidcnii,-  K.-v.-r  ..f  In-lai.  1.      I,an,-,-t,   182H  and  1830 

(i.-Hilti.T  ,1,.   (Uaiil.n.    I),,   ri.lentit,--  <lu    l^pl,,,-  .-t  ,1,.   1h   fi.'.vr,.  tv|.)...id,-       Mem.    de 

I  A.-ad     d.'  nnVl..   T.    VI 1,    18.!.'>. 
I'f.uflV'r,  Uiitranu /.ur  (iwhiiliic- dcs  I'etecliialtyphus.     Bamberg,  1831. 

f.2» 


!* 


•13  4. 


630 


i.iTEiiMrni:. 


V,-\vy   l..tt.-r -n  T^pliU-  F.'vir.      Diil.lin  .l.iiini.  ..f  M.  .1.  S.  , .    iK:iii. 

t;,.rl!iii.|  ;.i..|    I'.iiTh.k    (III  th.' T\pliu>  Ki'v.r  whicli  ..r.iiiiv.l  :it   I'liilu.l.  Shin  in  WM\. 

Ain.i.  .l.iiHii    ..r  \I.il.  Srli'iK'c.  \m|.    I '.1  Mini  -jo,   is:;: 

'I'l -on.   A  St:iti-lli  ;il  In^inirs   into  Fcv>r.       l-Minh.  .Ii.nrn  ,  \dl.  .Ml.   \K\h 

Ijniv.-.  l>n   tlw  StMt.'  ••(  ill.'    l"u|.il  in  'I'viilin-  :incl    llii.    l-.-..!'   rHlhnlonini  in  Certuiii 

Cii-c.^  .il'  r.v.r       DnI.I,    ,|on,-n  .    l>;s 
Vull>'i.\.  l)u  •■■r,\iiliu-   IrMT      .•tell'   hi  lirvrv  I  \  |  .lioiilr  U  An(;li'tcrre.      Arch.   i;i'n.  di- 

nn'^il.,  IN'.'.I, 

Kdillu'll,  Tri-iili-. T>|.lni.-  K.v.t       I.Mnd..,,,    \KV.I. 

AniliTsou,  Ol.-irv.  Mil  T,v|.liii-.      (Wa-^'.iW.   IS4li. 

Cliri-li-c.n.  An.  ( '■ 'iilinucil    K.mi-  in  Twi'ilii-.  S\>l.  ot'  I'rurt.  Miil  .  Vol.  1  ,  l.omlon. 

IMU. 
l,iini|oii/,v,    Siir  I  .ipiili'inii'  ili-  I\|ilni>   riin-rnil  i|iii   »   rcmiv  »    l!(iiii.«   en     183'J— lh4l>. 

.\nli.  iiiMi.  ill'  null  .   1S4'J. 
Krnii.il\.  till   tlh    Conncv     Ki-twri-n  Kuininr  and  KrMT  In  Iri'liiinl  I'tr.      Diililiii.   l>-47. 
Stokr,-    mid    Cii-iik.    On    tlio    .Mortulii;.    of    .Mid      l'riiititioTn''->    in     In-lnnd.      Diildin, 

.('ilM-n.  of    Mill    Si-.,    Ih47,    Ir-ls. 
UiiiiTod,  Clin.  Oli-iTv.  ..1!  Coiitiiiiicd  Ki'ViT  iit  St.  Itiirtljoloniiw  -  Ilo^,.      London.  \M><. 
Griivis,  Clin.  I.i-ct.  on  tin-  rnutiii' of  Mcdirini'.  II.   Kd       Uiildin,  1H4^. 
Viri-liow,    >littliiiluiiL,'in    iil.ir   dii-    in    OIhtm  lilf>i 'ii    liiTrM-lii'iidi'    T\  pluiMjiiiifriiie. 

\'irili.    u.    Ui'iiili,    Arilii\,    lid.    II.    1K41I. 
Stiili.  Zur  piitlioloi.'.  Aiuitoniii- di- ol.i-r-i  lilc.-.  'ryplm-.      Kl'iMidii.  S.  :!•_':!. 
V.   B.-ircn-iiniin;.   I'idiiT  din  'I'v  |di\i>  in  OIpitmIiIi -ifii.      llai- '■  -  .\rili.   X.  4,  1840. 
Vindiow.   Kriii-ilii-  uliiT  din  oliiTvlili'^.  Tviilui>.      Viivli.  .^nli  .   lid    111.  1H4'.». 
Siiclianck,   Mittlit-il.  iilicr  ilir  T\  pliu-t'iiidi'inii'  iin  Ti-Mlicncr   Kni.-i'.      I'rairiT  A'iertid- 

jalirsclir.,  Bd.  L'l,  1H4!1. 
Scliilt/..   r.diiT  Tvpliii-  i-sanllicnatiiii-,  iK-iiliartitct  in  den  WintiTiiionati'n  di'S  .lalircs 

1847.  184H. 

—  Kl>i'nda,  Hd.  ■.'•-'.   tH4lt. 

FinuiT.  Dii'  walm-nd  il(.,- .lulirc  1841',— 1848  im    I'r«i;er  ullu;.    Krunkeiiliause  btobaih- 

ti'ti-n  Kpidiniii-n,   l84i;— 1848. 
_   Kliriida,   Hd.  -J;!.  1841'. 
JenriiT,  Tviitm>  and   Tviilioid.      Kdinli.    Monthly  .Imirn.   of  MmI.   Siii-nre.  Vol.*.  IX 

and  X,  18411— 18r)(l. 
Chri>tioMiii,    On   tlic    I)i-trilnui..n   of    Kt'ViT    l*atii>iil.»   in  a   Hosjiital       Mnntlily    .Med. 

.loiirn.,  18.V>. 
Flint,    Cliiiii'al    Ki'port-    nn    Conliinu-d    Kcv.rs   Hau'd  on  an   Anuly^i.-  of   li;4  Ca.-cs. 

Hiitlalo.    18.V.'. 
I.indwunn.  Dim-  Typliii>  in  Irland.  Ix-oliai-liti-l  iin  Soniint-r  Is.'ili.      Krlani;i'n,   1853. 
FiinrPi.  Prpuvi'>  iliniinirs  di-  la  non-idiMitili'  dii  typliu.'  it  di-  la  liiA  n-  typlnndf.     Ga/,. 

nii'd.  do  i'aris.  18iV4. 
Vin-liow.   Iiii-  N'otli  ill!  S|ii'!->»rt,      Wurzl'iirt'i-r  Vi-rliandl..  Bd.  Til,  S.  WTt. 

—  nil'  lliiiiiifnpidi'Tni.'  in    rntPifraiikiMi  iti-.      Klii-nda.  S.   l(il.      (  Boili  artitlo.i  alco 

in  (Ji'S.  Alniundl.  iiu- d    Gch.  d.  oH'i'ntl.   Mi-d.  n    Si-in-hrnli.liri.  ) 
Biirlli  't,  TliP  Fi  ■••r.  of  till-  I'nitcd  Stati-s,  4lli  Kil.  I'liiliidi-lpiiia,   IS-'ifi. 
.laqiiol,  Dii  typliiin  di'  I  aniip<"  d'Oriiiit.      I'aris,  \X'*\. 
Pi'ai-iK-k.  On  till-  Varii-tii--  of  Continin-il  Fi-vit  and  tlnir  |)i-iriininiition.     Med.  Timep, 

18;V.. 
Coili-liiT,   I'l'^iinir'  d  line  nii'iiioiri'  stir  I"  typliu>.  oli-orM'-  pn  \'al-.lc-(irare  etr.     (iaz 

di-s  hop.,  .lull,  1«.'>'1. 
MavfT    Dii- Typhu-i-XHiillii'iii  i-ti-.      Wichi-nhlutt  di-r  \Vii-n(r  AiTzto.  18.W. 
Mi-nnti.-.  I'vii  h.  elin.  ft  anatoin.  -^urquelnni's  iniintiide  1  hist,  du  typhus.    Thi-se.  I'ariH, 

ls.-,7. 


ii 


I.I ri:n.\  ii  m-: 


(i.tl 


Muri  1)1 


lIi>torv  ..f  till/  Di.-liii 


,  Kiii;ImmiI  himI  Kt 
rkaul'.  Typli    rxu 


'f  'rvpliii-   iind  'I'v  |ili,,iil    Kevi-r.      Miil,  'I'i 


I  Iff, 


itln'rijut.  in  tintli 


re  Sfliiislii|Kil,  ..ir.      l,,.ii<l,.ii.   !► 


1k:,i1 


Virvli.  Arrli.,   Hil,  4:!. 


Wuiidi-rlicli.   I'i'Imt  (Ini  NoriimlviThiiil' liiiigi-r  t .  |ibiliir  Kriinklii-il.-l'. 


Arch.  f. 


Iiv-ii.l.i.r,   Ilcilkuiuli',  Is.'iM. 


Kiililo,  Aniit.ini.  Mittlnil.  uIht'I'viiI 


iitliurimt.    (iun-li.  im-.L /.citscli.  I80H  u.  Greifu- 


i<i.  Ml. '(I.  li.'iii..  na.  II 


Mui-rhi 


.1. 


n,  (In  lli.'Cla-itii"il 
urn  ,  (i.-l  .   |s:,s. 


ionaritl  NonicniJatMrLMif  C'..ntirin.ii  Fpvits.     Kdinb.  Med. 


HuniUiiT,  l)ii  t\  lil 


in-  I'lihli'Minni* 


|.nn-.| 


|M''  II 


Tnlll..,,.         I'l 


Ihf.l. 


Si'hnc|i|i,   I).-   Ii,\i.>  l\  |>lii,|iir.  ,t  (ir   I  ;i|>|iaritioii  dn   Ividi.  e\ttiitlii'liiat.   en    Ki.'ypti'. 


I'll,  in.-d..  0,  I  ,  18(;i. 


('uzaliis.  K\i 


inii'ii   tlii'..rii|ii<'  .1   |iriitii|iii' dc  111  ijiK-linii  rclati\f  li  la  diictrinc  di'  1  idi'ii- 


lit.'  .Ml  ,lr   I 


Kniilc.    Diri'inMitiill.'    Diai 
Niitiirl'orscli.-Vi 


I  iiiin-idi'iititt'  dn  typliiis  dc  la  lirvri'  typhoid^.     I'n  inrd.,  IKi;i. 


iici-i'   d \aiitliciii.    voiii    Alidi'iiiiiialtypli 


us.      liir.   d.    3ti. 


lHi;i. 


<;rirBini;,T.  I'dnT  KlccktUd.cr  itc      Arrli.  d.  Iliilkniidi',  Hd,   II.  18i;l. 


AiMiiM  IntVctiunskrHiiklii 


Tlicnip.,  2.  Autl..  18114. 


i-n  :  .\li.-cliii.  KliTklicliiT.    \'irili.  lliindli.  d.  spec.  I'atliid, 


ir   HiMirtliiil.  diT  tyidiiis.  Kraiikiii   iiiit  lliH'c  der  Wiiriiii 


■pi 


lliilk..  ih; 


Wundcrliili,   Hcitrai; 

Mini;.      Arcli.  t'l 
Duncan,  On  tin;  Intmiliicti.in  of  Kcvcr  iiitii  \. 
Gdurricr,   It.iat    d  unc  cpidiMii.  dii  typliu.s  (iIimtvc  a  Toul.ni  1804.      These  3I( 

IHtli;. 
.MurcliiM.ii.    Pi.-  t\ 


ver|)i<(d,  etc.      Med.  Tiine.^  ISCiL'. 


ntpellier, 


pliiiidcn    Krankliritcn.      Tehers.  v.m   Znl/.cr.   ii.-rliii,   1807.       1 V 


lllplel..  eidleitiiili  ,,r   the  litenitll 

.rk-,  ) 


(  \  ery 

specially  of  tl Ider  Kni^lish  und  French 


Rosenstein.  Mitth  iluni;en  uher  diis  Kh'cklielier.     \'ircli.  Anh..  lid.  4.?,  18«i8. 

V.  Tresknw.  Vorl.  .Mitlheil.  uher  York.  d.  Typli.  exanthein.  etc.    Kerl.  klin.AViichtnPchr 

Xr.  7  11.  8,  18(18.  ' 

Naunyn,  Bericht  uher  den  exHnthem.  Typhus  in  (Miireussen.    Berl.  klin.  Weehenschr. 


Ni 


18(18. 


Seliicf. 


(•decker,  A'erhuiidl.  der  Berl.  nied.  (i 


Becher,  Mittheiliini;en  aii-derTviil 


•s.     Berl.  klin.  Wochcnschr.,  Nr.  'J--,  18()8. 


Nr.  4!i.  M  u.  .'.I,  ls(;8. 


liliiis.pideiiiie  ill  Ostpreu.ssen.   Berl.  klin.  Woclienschr 


Miwler,  KrfahrnnircMi   uher  di.'   Behandluni:  dPs  Typh.  exanthiinat.  etc.      Greifswald 


l8liN. 


Varrentnipp,  Die  Kleeklie'.en'|ii<leniie  in  Kninkfiirt  u.  M.     forrefp<indeM/.l)luU  fur  dii 

inittilrhein.  Aerzte,  Nr.   10  u.  11.  1868. 
Virehnw,  Teher  den  Huniiertyphus  und  einisre  Nerwiindte  Krankheitifomien.     Berlin 


1M«8.    (Virch.Rc-    .Vhhiindl.ausd.  (id.  (I   (irteiitl.  Med. 


Wegener,  Ziir  I'nthol.  u.  Thecal),  dei.  Tyiih. 

Vital,  Le  typlm-  dans  la  prov.  de  C.inslatiline  en  18(1(1,     Ker. 


u.  .Sncheiilehre,  S.  4;!3.) 


18(10. 
Kanziiw.  Der  cxanllienmt. 

Niith.s;  ,:ides  ini  .Inhi 
(iriitzer.  .'-'■talislik   der   Kpid 


iintlieniat.    Jahrli.  f.  KInderheilk..  I81I8. 
ies  ineni.  de  med.inilit., 


1  yjinu 

-  nil  1 

sip 

IT  18r,8. 

Puts 

Ian 

clllie    VI 

III  Tv 

ih. 

u.  18(i;(.     Deulsch    Arch.  f.  klin.  .Mid  .  Bd.  VII 
l.'diert.  Aeti(iliii;ie  und  .--latistik 


reus>    Reg.-Bez.  Gunii.innen   wahrend  des 
11.    18(1!). 
■xiinlhiM'iat.  in    Bn'-    11  i.  d.  .lahren  18(18 


i.  d.  .Ill 


des    KiickfalKietHTs  iind  d^,    Klecktyphus  in  Brcslau 
ahren  IKilK  imd  |8(m.     Deut'oh.  Areh    f.  klin.  Med..  H.  .s!  4  u.  ;'.,  Bd    VII. 
1,  Statist    Bericht  iil»'r  dus  Allerheilicjenhospital  Breslau.  1870.     (S.  105f") 

cxanthemat.  Typhus  in  klin.  und  "-aniuitspiiliz.  Be/.iehung.    Nacli 


I'assaiiiT.  Teller  d 


«:12 


J.I  I  in  \  rri.i. 


3-"^ 


ll«g 

1^^ 

mm.. 

■ 

H              tMB 

II 

Hi'.il.ii,  liiini;.'.ri  w.iliriii.l  il.  r  ...-t|iriii>-. 'I'v  |.lin-i-|iii]iiMii' i   .1    .liiliri'ii  IstiHu  lhi;'.l 

Krliiip^rri,  |S7(I 
J'rrrirr,   Kllri-  il.'   lit  irii-civ  ii   i\|,liu-  ilim-   In  |ir..MMii'  il  AIlj.t.      It.'c-.  dcs  iiifiii,  do 

I I.  luilit  ,  l^Tii 

W'uriilfiliili,   I'i-Lli    .ih-   Iliai,'Ti..v  ,|r-    Kl.c  k!_^|.lili^       \'..|kiu.   SiitiumI.  kliii.  Viirlmgc, 

Nr.  l!l,  InTI 
Murilu-'Mi,  On  tli'-  I'lrio.i  ,,f  In.ul.at.  ..i   T\]iliiis.  Iti-lup.-iiii,'  Ki'ViT,  eU-.      St    'riinina» 

U..-,,.  U,),.,  \-,,l.  Ill,  INTI 
()l)oriii.'i' r.  I)i.-  i'i>uii    Kail.-  .lir   li.iliri.r  KK  ■  kt\  |,lni>r|.i.iriiii,.  von  1873.     Bcrl.  kliii. 

\\^.l■ll(■ll^.■llr.,  Nr.  :l(l  u.  :il,   l^T:;. 
—  Zur  ('i.iiluiii'iri  di'^   wicdrrki-liroiid.  m  und  d.  s  Kli'rktypliiis.      < '(■irlmll)l.  f.  d.  ined. 

Wi.-M'M.-d]..  Nr.  ;!i;.  Ih;:;. 
Zulzcr,  Ziir  Actiiiliii;ic  d.-  l-'lrrkt\  pliii-.      Nmli  l!<'ol,ai'litiiii(;eTi  iius  drr  liiTliinT  Kpi- 

diiniij  Mill  1^7:1.     X'in-trljalir-ilir.  I'.  i;irii  lill.  Med.,  Jan.,  S.  18,'i,  und  Zrit-clir.  t'. 

prakt.   M.'d  ,   Nr.    1.   I.s7l 
Ilidi-iv  lii'..!.arlitiin^'in  uKirTspli.  ixantliiMimt.  und  l-'il.r  icnla.     l>.ir|iiil    ini'ii.  Z<-it.M'lir  . 

lid.  w  i>-ri. 

IlritliT.  H.Ti.l.t  iiKiT  di.'  ini  .lalir.'  Is7."i  aiif  d.T  Klinik  iiiid  Al.tli.  d.-  I'r.d'.  I.nhcl 
1 !>a   Ill-ten  K.ill.'  v..n  l-"lrckty|Om.<.     Wi.'nir  rn.'d.  Jalirb.,  187.'i. 

I,.'l..Tt.  Kl.'rkt\|.lni-  V  Zi.-ni".!!  -^  llandl..  d.  ^|.lc.  I'ntli.  ii.  Tlienip.  l'.  Aiill.,  Hd.  II. 
Is7i;. 

Wy-,   Kl.,kti.l.,T      (liiliarl  ~  llaiidK.  d.T  Kin.l.rkranUli.,  lid.   II.  1876. 

F.   lIiTnnann.   Pi.-  KI.-.kty|iliiisi'piiliMrii.-  v.'fi  ls74iind  187').      I'rtorsli.  ni.'il.    Wixdipn- 

-.lir .  Nr.  \i:.  1S7(;. 
Martin.  Ktiid.'  Mir  li'iuloinii  it.' ilii  ly).liii<  daii>  !.•  d.'part.  ilu  KiiiistiTc.     'I'll.  :-c,  I'liri.-. 

lH7i;. 
Kai'/."r.>w-ki.   I'i'Ii.t  ilio   K|iid.'ini.'  il.- 'I'v  pliii-  .■Mintli.iiiat.  ini  Spital  d.r  lianiilii'rz. 

Sidiw.'strrn  in  I'.i-.Mi.      I).'1U-.1m- nif.l.  \Vo.li.;n-.lir..  1877. 
--   l)i.'  kalto  Liift  al<  .\ntipyn-liciiin.      Ktifiida.  187'.i. 
<).-iT.  r.l..Tcli'n  Tyiiliu>  .x.nitli.'iiuit.  in  Wii'ii.     Med.  .lalirl...  II.  4.   1S77 
Daiiiry  d.'-  I) rt-.  I!.-lati..n-  .l.'  I.'pi.|.'-ni.  di'  ty|ili.  ii.'ti''(liial  .!■■  I  il.-  M..|.n.'.    Arcli.  de 

nii'.l.  naval.*.  1H77 
V.  .S'li.'V.Ti.   I'cti.M-  .lie  L'l-e'.Mi  .1.1!   cxanlliini.it.  Typliu-   in  der  A  rni.'.'  zn  .'ninifi'iid.  n 

.-anitat>p.di7..  Ma.~^^■l;l  In.    Vi.  rliljalir-rlir.  f.  irorii'litl.  Mi.l.,  1K77. 
<Ji-tiii.  Happ.irt  .-nr  !.-  .■■pi.l.'ini.  ■-  d.-  1X77,     M.-m.  .1.-  la.ad.  de  m.-d.,  T.  ■11.',  1878 
iJenary.   K\irz(T  liiri.lit  iil..r  .Ii.'   walinml   il.v  Jalirfs  1878  ini    li.rl.  ,~t.'i.lt.  liura.ken- 

lazarcth  v.irijck.iiiiiii.  Kail.'  v.'ii  Typluis  exKnthoinat.      Dciit^.li."  iii.'d.  W.i.'lifri- 

■•ilir.,  Nr.  •li;,  1S78. 
Ilartinann.   Di.'  l.ii  Ty].lin-  isaiitlninat.    aul'trctond.n    Krkrankiini;.'n  iI.t  Ilnnirs^'ani'. 

.\ivli.  .l.T  (lliri'iili.ilk      IK7!). 
SHl.iin..n.  li.'ri.-lit  iilier  die  Hirlin.r  Fl.'.'ktypliu~.|  1  I'  mi.'  ill!  ,|alir.-  IH7!'.     Iiiaii'_'.-I)i.—  . 

H.rlin.   IHSII  un.l  I>.Mit.«-li.  .\i-.li.  f   Miii.  M    d..   1880.      i 'Ph.' arti.-l.- ..f   li.iiarv. 

Hartnuinn.   an.l  .SaloMi..n    nl.r    t"   lli.'    niat.rial    i.Iisitm.I   1.\    m.'  at    tin'    H.tI. 

-t.ill.    liara.keiilazanlle   at  M.'al.it    i 
I'i-I..r.   Die  Kl.'.klv  pliii>.-pid.'nii.-   j,,   ()!,.. r-.lile-i.n  ln7i;— 1877.     A'ii-rtiljalii--il-,r.  f.  !;.•- 

riehtl.   M.-.I.,  H.l.  'J'.i.  1.  18NI. 
(i.iltdainneT.  I'l'ln-rili.'  Ki'>l-  iiml    l."eiiliaii-.i-  I'ur  .lie  arineren  V.ilkM'lu.-seii.     Vi.'rt.l- 

jalir.<lir.  t'.  ;,','ri.litl.   M.d..   IM.  liii.  '.',  Issd 
Kiuk.'iilier^.    Znr   I'atli..lii^'i.'  uml   TliiTapi.'  il.'-  Tyjili.   i\antliciiial.      I),  iii.-.li.'  in.'.l. 

\Vm,  li..n-.lir.,  Nr.  4^1— .'.1.  IKSd. 
ll.-inip.'In.  I'l'li.T  |-'l.Mkl\pliii^.      I).iil-cli.  Ar.li    i'    klin.   Med..  188(1. 
M..ritz.  Kurz.T   Ii.  n.lit    nli.T  iI.ti    Kl.*ekt\  pliu-  im  «.'il,l.  (tlmcli..»spital  18711 — 1880. 

I'etcrsli.  m.'...    \V..i-lM'n-.lir  .  Nr    17.   ISMl. 


i.iri:ii.\TrHE. 


6;j;3 


iiwciHUiMir   wiirriiir-, 


Herrtnunn,   Bfitrui;   zur  Ai 

I'ctlTsll.    Ilifll.     \\(.()]ill-il| 

JuMi'WHv,  T\|ili.   K>viii„  .Nivv  V,,rk.      Hu.-t.  .M..,|. 
OutL-tudl,    Klrrk-   iiikI    ltucklalllicl...r  ill   l'r.u.«,.,.li. 


.'r.  L'ti,  IHM. 


(in.l.iti^'irtcr     K.-idir   im    KlmltviOim 


iiid  Sill-;;.  J. 


urn.,  1(SM. 


koiiii;!.  pn-ii.-.-.  ^tati.-t.   Hii 


I'.'  rliii,  IHHL'. 


11     Kr^uii/.-II.-li  zur  Zt'iL-chr.  d. 


Mi.lia,li>,  Dor  CMiMlh.MMat.  Txpliu-  in  ivt  nis>i>,hrn  Aniiof  nul   d.r  llMlkaiilmlliiMs.^I 

1H77  7H.     (ti»-tcTr.  iiiililai-arztl.  /I'it-cli.,  1MM2. 
Aluttaiid  Hli.ns  Micr(..„rguni,nis  in  T\idius  F(v,i       liiit,  Mrd.  Juuin..  I),-,-  ,  \m:i. 
Wfichscll.Hi-Mi.  r..l,or  .-ini^i.  sult.'iic  f..niplia.li..n.-n  dl■^  Tyidi.  .•x.mth.Mnat    in  una- 

tmn.  u.  iii'tii.loir.  Beziiduin;,'.     Aiii;i-in.  Wifmr  nii-d.  Zrit.,  Nr.  L'l!— L':!.  l«H;j. 
CurMliniann,  Kl.cktl.l.ir.     /,i.rn>Mn  -  llundl,..   Hd.  1.',  3.  AuH,.  Ihni; 
MuntzW.   VvUt  dii.  Vorl)n'itiini;  d.s   Klirktyiihus  iji  l'rru»..|i  (Lis  lhH5).      l)i,,.  Her. 

iifi  1HM7.     I  TntiT  (iutl-tadf-  I.cituni,'  I'l'iirl..  ii.'i. , 
jHn.,w.,ky,  r^LiT  da-  Kvanth.ii,  dc-  Kli-cktypliu-       Intornat.  klin.  l!und-,l»,i,,  1M88. 
Sei'liircr,  I)!,.   Kl.'cktv  |)liu-c-|,idrrnic  in  d.-r  -t.idt.   K  ninkmanstalt  zu   Kc.ni-.1«TL'  I8«0 

Lis  18HJ.      Ii,.rl.  klin.   \Vo,-1i.m,-.  hr..   Nr    .".I   u.  .VJ,   IHHH. 
R.'icl..,i;,..M,ndl„.it.ai„t,    \  .TortV.nlll.hu.i^'.-n    d.-.    f.-lMr    ..in,-    Flrrktvnhu.M.pidHni,-   in 

Mundi-lpui-i,',   1H88. 

Chn.^tir.  A  (■«.■*,•  ..fTyphiH  Kt.^..r(■ ,11,-.  with  II,Mnat,.,nc>i,.     (ilaM'.-w  M,.,|   .),,urn 

l)w..  IKHH. 

M.,n.„u,.t(-,K.h..z.('ontril,,.t.ar,-.tnd..dutypl,...XHnth..mat.     Gaz.  In-l,,!.,  Nr.  L'8    1888 
HIawa,  KUHl...Mir!..  typh.  ,.xanlli,Mnm.     Arcli.   H.dir.ni...  dcMnrd     III     1     IHH'I 
Th.„n„t.   I,.,  typh.  ,.xanth.-nnit.  d,-  lil,.  T.idy.     Ann.  d.  hy«.  p„l.|.  ct  do  nu'd.  l.Valo, 
I  H!(  I . 

M..y,  Zur  K,.nntni,s  d,.,.  llan,n,.|„l,in...halt,.s  d.-s  m,„..s  I.ein,  Tvpl,.  -xanthonrnt.     Dis, 

Dorpal,  18111. 
Thainot  ,.l  Culnn.^t,.,  N„t,.  ,.,.r  ,|n..l,|„...  oxanM-ns  d-  nung  dan.s  lo  tvph.  oxanthenrnt. 

Ann.  di-rin-titut  I'astciir,   iH'.i-J. 
Thoinol,  Art.  KIc'ktictKT.     Traito  ,!,■  mod  ,  1802. 
L..wa.s,lu.w.  r,-l,,.rdi,.  Mikr.H,ri:aniMn..ndrH  Fiooktyphus.   DPUt><chon,pd.  W,„lu-n«ohr 

Nr.  l.'i,  18112. 

—  rclM.rdicMikn.pani-ilon  d.-s  Flcvktvplm.,      KL.'nda    Nr84    i8'i- 

'"•'■ ""■  ^'''•^•".vpl,,,-  m,d  fh,.U.ra.      M„rl,iditat  dcs  arztl    Standes.      Petersl,    ,ned 

\\  oilicnsrlir. ,  Ixirj 

limnnan  and  CI sinan.  A  Sin.ly  uf  Typlm-  Fovor,  etc.     .M,.,l.   I{,.,.„rd,  IHirj 

N.'ttor.   Kti.d..i;io,.t  prci|.liyla\o,|„  typli.  .■xanthoiiiBt.      fni..,,  „„'.d.    181« 

—  On-.,,.-  l.n.ltonn,.  do  lopidoinio  typl,i,|uo  do  180-.';!«  on  Franco.     Soniaino  nied 

.Inni.   181)8. 

—  I'n  oa-  do  typhii,  noronnn      S.w    mod.  dos  liopit.,  .Inni,   I8!i;!. 
Kli.d„i;ioot  pn.phylaxiodu  typli.  oxantlioinat.     Klionda.  .lull    ISM 

Do  linin.  N..to  Mir  lo  typl xanthon.at,  cl.sorvo  a    liovroutl,  dan-  lo-  „rond,M 

■1  anrioo  l81):i.      Hull,  do  JWoad..  !KIt8. 
C.mdM.nmlo.   Donv    oa-  do  lypj,.  oxantlioniat.  avo,-  l,yp..thonnio,      (;„z.  Iiol.d.,  Nr.  :i(., 

"-  Siio.  inrtl.  do-  Inipit..  IKli:;. 
Unoorai.x,  Sur  Fopidondo  ,lo  lyph.  oxantl,on,at.      Hull,  do  laoad.  do  ,no,l,.  I81.:i. 
I'nai-l.   N„to  <»T  lo  lypli.  oxanthoMiat.  on   Fnmoo  18H8  etc.     Bull    do  1  „oad    do  mod 
IHUI, 

—  Typli.  .xanlliomat.  au  Havn.' en  IHli:!.  otiv      Pari-.   1.811:-,. 

' ■''■  *■■•'"    '"■'"'■  ^''•-   ^■>  >'■    *'■    '■'^'•'•i     -  Chantoino.sso.    S-K-ieto  n.M.    dos  hopit  , 

18!l.-i.  -_  li„l„of  ot  iinilil.  Somaino  mod.,  18i.H.  (Tlioso  w.irks  ti-oat  ..f  an  o,.i. 
.lomw  wlnoh  l.roko  ..m  |„  Mil,,  i„  ih;.8,  and  sproad  fnim  thoro  to  tl.o  prisons  of 
I'uris  and  oriviron-.  1 


proniiors  nmi- 


¥": 


W 


M  M  '■ 


t;;ii 


i.iii.nMi  ni:. 


K.1-.  Ii.   'I'niil.    .|.  -  iriiihi.ll'-  r|.li|.  Iiil.|ll.  -         I'lili-,    \>:>i. 

|)iil>i<:'<I    ISriilil.  CmiiIi'iI'     ;i    I  >  nicl>    Miial -|<itlli<>l     il    Inii  lirii  >l<'i,-     ilii    i\|.li     .mui- 

ih.  ,,,,,1.      An  h.  .!.■  ii„-.l    .  \|Hr.,   Nr    :;.   IVil 
(  .iiiili.iii;il.-.    l.,M\|.li    .  \!iiilli.  inril,  iIm/.  li-  M.  illiinl-        liull    :;.ii    ,lr  tli.  rii|i  .   inm. 

|1.  -  I  .ili,|ilii  allMi-   |iullli"li     i;ni\i  -  (ImIi-   !■•   t.^  I'll     <\llli  ill.  mill         ij'ilnlu,    IMI'I. 

l),ii-.|i-iiii. .  I.r  n  |,liii- ,l:,ii- I  1 1|..  ,  I,  i^;i.;      (ill/,,  liii,,!.,  Nr   .;'.i  -  4:;.  1n:i.".. 

Iti.lit.r,   r.l.rr  I- I.-.  kls|ilni-       I  >.  iit,-.  In-  mid.  \S  ...  l;i'ii-i  lir. .   N  r    :;|.    Ihii:,. 

.M..-I.T.  Kl.-.kty|.li\i-.     Kiii.nl..m-  Km  \  k|..|.,i.lii-,  :;    Ami..  Ih'.i.. 

Siulliiiiiiui.  ('•.ntnl.iil.  a  1  l.i-t..ii-.' ilii  l\|.li    i-MiiillirTiiiit.    i;.\ .  i|.'  iii...|  ,   N  r    H,  mO.'). 

ru'tni-kv.   I'.l..r  ilii-    Aiiriri't'ii   il.-  |-'|. .  kli.l.'T-   in   Srlil.-i.ii  iih.l  .li.'   /ii  .l..>.-i-ii  \'ir- 

liiiluiii;  L'''iL'ii.  1.  11  Mii--i-.  i;' 111      \  I.  rt.  Ij:ilii-i  In-    I    ..|I.  nil    (i.-ini.lli.  il-|.|l. .  Ih'.i'i. 
I..',  .iiliiii'.il.  IcKir  .111-  \  .irk..iiiiii.ri  \.iii  H'l.  rkti.  I..r  iin.l   II. .  urn  n-  in  Kn-liiii.    /..iw  lir. 

lur  ll\;:i.n.'  un.l  liir..i  -K niiikli..   li.l.  l'*.   Iv,; 
I-'iliil'.vv ,    \'.ir|.-iiiii;.  n    nil.  r   ii.  iit>'    I  iilV,  n.in-kriinkli.  il.ii    liii    K  iml.-iill.  r       .\'      i|.  in 

Itn-i-.li.'Ti.      Wi.n.   IS'iT. 
N.tl.T,   r'l.-i  kl\|iliii-.      'I'liiil.' .1.-  in.'..l    |.iir  Hr..iiMcl' I.   l^-;iH. 

Mil.- \Vo..n..y,  N,.t.-..n  tli.    Kti..l..t:\  ..rTvpliii-  K.-mt      Mril     M..I    .I..urii  .  Apr.  Iv.ih. 
l!iilf..in-   nil. I    I'Mrt.-r.   A    l!.-.-iin-li   ii.l..  lln-  l!ii.!.-ri..l.L'.\   ..f  T.i  plm-    K.-\.-r.      I'riliniiri. 

N..ti.-.-.   K.linli     M..I    .|..uni..   Nr    L'.   lH!i!i. 
I'.l.-.  A'.-rl.ri-ilinit:  '1'-    Kl..  kn  pliii-    in    H..liiii.n        TriiL'     m.-.l     W  ...  h.-n-.  hr.,   N  r.   IH. 

IS!  10. 
I.ittli-j.ilin  iin.l  K.-r.  An  ()iill.r.'»k  ..f  T.vi.liii-  I-'.-mt      K.linl..  Mi-d.  .I..ui-n..  IH'Mi. 


Til.'  nil.. VI.  t.ilili.iirmptiv  i-  ii'.t  inti-ncli-il  t"  l.i-  (•nrll|ln•lll■n^iv('.  It  iiiclmlrs  the 
ni..n.   ini|i.irt:iiil    |.ul.|iiiili..ii-   .l.-iiliiitr  uilli  tin-  i-|.iili-iiii..l..u'.v.  imil   »   miinli.T  nf  ottiiTs 

wllic  ll    .-..lltllill    -..|ll|.    >|ii'rillll\     Mlllllll.lo    (lillll. 

K..I-  til.-  ..1.li-r  liti-nitiin-.  .-|»-i-iiilly  tin-  Kni:li-li  und  Kn-mli  up  |..  IKC.-,.  tin'  niulir 
i.-  ri-fi-rn-il  t..  tin-  rln--i.-:il  wurk  ..f  Miiri-lii-.m.  Tlio  phiih'  wrk  iinil  llirsilis  HHndlnicli 
dir  tii-lnr -i:.'..^'riipli  riilh..l.it,'ii.  i'..ntHiii  ii  ili-taili'd  Hccuuiit  of  the  histiirj-  and  giii- 
i;nipliii-  ilislriliiitiiin  ..f  typhus  fi-viT. 


MHiiii 

yi^, 

r 

IP*' ' 

i 

■   i 

"^^^M^mi 


^**>i 


INDEX. 


Aiili'iMKN.  T.ulpiiti..ii  ..r   in   l\|>l,..hl.  L'l  I 

ill  tv|i[i.iiil  fi'vif,  S4 
.\li-ci'>»,  (•iitHiii'iiii-,  ill  i\|iliii..  :,:;:; 
Ai  rliiiiiiti/alioii.  ili.i'ii-i'-.  7:; 
Ali-lii-i!.'  ca-rs  Mt'  t>|>liii-,  .'.Ti; 
A-.-,  iiilliii'tiri' ..I'.  .Ml  ty|.li..iil  iiil'i-iiii.ii,  -'ii; 
Air  ill  tnui-iiii--ii.ii  ..I'tv  |ili..i.|,    l'l 
Alliiiiiiiniiria  in   |.r..i;ii,i-i-  ,,('  tv  |,||,,i,|    ;;:ii 

in  ty|ilii.iil.  IHi; 

in  lyiiliii*.  .'.Ill 
Al. -nil. .lie  lirvrra^'.-  ,1-   H|.ln.i,|  |,r.i|ill  \  liic- 

lii-,  47 
Aii-iiholi.iii.  Iy|.lioi.|  „imI,  :;■_'.'* 

ty|ilin<  mill,  n'l:iii..ii  l.ftwr.Mi,  .">(i4 
Ai..|».(iii  in  ty|ili.,i,|.   I:l-J 
Ainaiiro-i-  in  tynlLiiil,  'JHC, 
\inliiiliit..rv  tviilnii.l  iVvit  -'.tir, 


■      ■  ■      ■'' 
Ani'iniii    111    (•..iiva|..-,.nr.'    IV.. in    U|,li..i,| 

:ii;7 

An;;ina  in  ly|.li..iil.  -JKl 

Aiiinml  ln..i'iilali..n  willi  lvpli..i.l,  :!0 

Anihnix,    ty|)li..iil    an. I.    .liir.TciiliHl    ilia^'- 

n.i..i-,    JIs 

typliu>  an. I,  .lilf.T.niial  ilia;;ii..-i-.  i;ii:! 

Willi  typli.ii.l,  :!-_'7 
Anti-li..iii..<  ..(■  typli..i.l,  H'.i 
Antipyri'ii.' dni.,'-  in  Ivpli.iid,  41)0 

irii-tli.Mls  in  lyph  .ii|,'4.'i:! 
ill  typliu-,  i;l'i 
Antipyrin  in  typli..i.l.   li;-_' 
A.irla  in  typli..ii|,   Ir.s 
Apha-iii  in  typli..iil.  ^71,  •-'7.'> 
App.-liti'  in  i\  pli..i.l.  L'll.'i 
Ari.Titi-,  ..l.litcmtin^'.  in  lvpli..iil,   1(J9 

in  lypli..i.i,   107 

lypli.iiil.   Iii7 
A-iatic  .•li..|.Tfi  witli  typli.iij,  325 
Alavia  in  typli.iirl,  27M 

Haiim.uria,   IIJ 

Hiu-illus  of  typhis,  olin,  i.-al  nature,  482 

disseiiiiiiatii.n,  484 

entniiii'c  int..  Imdv.  JX7 

iiiicnipiirH-itic  naiiiri'  ..f,  48.3 

iii.mI.;  .if  ai.ti..n,  4S1.' 
i>f  tmiisnii^vi.ni.  4H(I 

nutiirc,  4H2 

rpuctiiiii  t.)  clii'iniial-,  488 
typhosus,  acids  and,  :>'.• 

au'ar  piiltun-<,  211 

animal  iniMiiIati.nis,  :!i) 

bttoilliH  c.li  an.l.  dirt'crpiitiati.iii,  4l;i 

binl.isry.  20 

carriers  .if,  40 

channels  ..f  iMitrani'i'  int..  liody,  ,38 
(if  I'xit  fr.iin  biidv.  32 


Ha.  illn-  lyph.iMiv  r\iltivttti..n.  28 
.In  ini;  an.l.  '.W, 

••il.'.a  .if  LTH-tii.'  jni.'i'  1. 11.  :;:) 

i;iill--|..ii.-  an.l.  L'lo 
U. latin  iiiltiir.  -.  2'." 
Iii-t.ir\.  2."i 
in  III. 1.1,1,    171 

IV.iiii  nis.'..|;i     127 
in  li.ini-iiiarr.iH  .  h!i,  'JO 
in  liiitt.T,  4i; 
in  .-adavcrs.  oo 
in  t'.'.-,-.  :!2 

\  ilalily.  37 
in  ritn-.'ill 
in  milk.  4.'i 
in  r.is.-.il.,-,   17.-, 

Ill  -pIciTl,    10".» 

in  urine,  32 

vitality,  37 
In  water,  40 
vitality,  3r. 

isiilati..n'.if,  I'r feee-.  33 

ini'iiiii^'iti.  an.l,  271 
.ii..rpli.i|.ii.'\ .  2ii 
in.iveinent.-,  27 
pii.imi(iiiia  and,  2'il 
11.. tat. 1  ciiltiiri'.  30 
-p.ire-t'.irinati.in.  27 
slainini;,  2W 
vitality.  34 
in  ,«.iil,  .'iS 
Haeteriiiria,   IIIO 
Hatlis  in  typhus.  r,20 
lii-d-nres  in  typh.iid.  1.30 
in  'yphiLs,  ,^33 
«uli<.utaneiius.  131 
Heer  as  tvphiii.l  iimpln  laiti.'.  47 
Mile  in  typhi. ill.  211 

Miliary    pa»sai;es    in     e.invaleseenec     fiiim 
typlh.id.    37--> 
in  typhnid,  20ii,  20!l 

p.'-t-iii..rtein  appeanini'.',  103 
Mlailil.T  iliani."'-  in  tvphus,  .'..Vl 
1      in  typhdid.  p.isl-nnirt.Mii  apiwarancc.  112 

HI I  elian:;e-  in  typliu.s,  525 

fr.ini  r..seiilip,  127 
in  typhi. i.l.  170 
hiiiterii.l.iiry,   174 
heninirl.iliin  in,  172 
I{liiiid-<Miltiires  in  dias.'n(isi.«  ..f  tvph.iid,  421 
Hl.i.i.l-seniin  of  ty].li..id  e..nvaleseeiitv  iHI 
Bl.i.i.l-vessels,  ohanijes  in,  in  tvphti-    .'.".'i 

in  typli..id,  lf;7 
B.ini'-niarniw,  hacilliis  lyplmsii-  in,  »'.'.  'M) 
Ml. tie-  in  c-..nvalesienic  fmni  typh..i,l,  378 
in  typli.iid,  pist-mdrtein  ap|)<'araiKi'.  89 


.  ."»; 


■tssJT.'.  ^I'JiX-'^^i:^s.r^  .y<-^J.  A.^J.-.=/"'-vi. 


W' 


«;)«) 


IM'I  \ 


k-- 


,1 

i 


^:if 


!''"'""  "' i'l  l.v|'li..i,l    •.':.-,  I Mr,„iT|..N  tl rv  ..f  tvi.li..i,I    •li 

Kr.'u-t..  iMllaiMiMMli..n  ,.1    niU|.l,..i^l     rC        |)i,,l..i.-  llilii-  w  ith' U  i.h.'.i.l    ::••: 

llr..ii.lii  III  lv|.l„.i.|.  L'|..  I>i;,.il,.,,  ji,  |N|,|„,i,l,  I'll'; 

I'""'-""""' iil.|..i.niiii-,   114  |liM/...i,:„li,.;,    i„     ,li„i.'ii...|-    ..I     iv|,li,,j,| 

-lllilliir,  ciilarrli  ..I.   ji,  ivplmiil.  L'4i;  (d.",                                                  ' 

Hn.n.liili-  ill  .ili'.rtn.-  |\  |ili..i.|    ::i>-J  m.  1\  |,li,.i,l     IIMI 

ill  ilii.u'ri.-i-  .,r  H|.l,.i,|     1(1.-,  |i„,  ,„  u|,|„,j,l.   J).-, 

in  l.vpliHiil,  L'l'.  .I.uiii-  .,.,n,,|.-,,,H..  4:,| 

Hn.iic  li..|inriiiii..iiiii  111  i\|ili.i.|    -JIT  III  i\|i|iii-,  i.li, 

''"•'I-'' rvMiiv,,! I    -s;  l)i:;..nM.    ,,r-„n-    in    lin-n.-i- ..f  n  1.1,1,. 

liiitl,  I- a-  :,  .  iirii,  r  ..t'  ml,,  l|.,ii  ill  i\  |,1 |  .-,;i|                                                       ' 

''■  IM   l\|,|i,.l,|.    I'.i'.i,    )i,| 

|...-l-ll,,,ltrlli   llli|„  liruh.'i'.    'HI 

<  u,,Mi,i    III  int. -III. ill  .11,11-. ji-i-.   in  II,  u  i.liii-.  i;l'T 

('aiiiii.-  fiv.r,  :;-.'i,  ,r,„  ,.  Vlm  ,„_,■,-,  h,    in  tv|,lHi-,  .-,47 

t  iitan-li.  -ii--tr,.-ii,l,-liiml,   H|,li,,i,i  |.  ,,,,  |  i,|,|ii  |„.,.j,|   „ii,|  u  i.liii-,'  i-,.|„ti,.ii    l„.i»,.,.„ 

(  iilarrlial  l\  pliii-.   .'i.'iy  .-.1,4 

(.'iTi'lmi!  aiiiMiiia,  -iiil.l,  II  iliiiili  ir,,iii,  :i;iH  m  iili  i\  i.li,,i,|    :',-j.', 

'"■'■"■\i"   I.M'l"'i'l     -■"  Ililhl>ln;;.»at.l   „-'a  ralli.  1    ,,f  imV,  li,  ,1,   in 

II--""     I"     t.M''"'"'       l"-I- !■"■     :.).|..:..-  I\l.h..i,l.    41 

•""'■•    I-'"  llrink-  ii,U|,li,ii,|.  447 

,,'-M''""''- ,■''!'  •""•'  '"  t^|■,ll,.i.l.  |...-t- 11.11,  i,|,|„„n,,M... 

(.  iM-c'l,r,,lMiilai  in.  ,  ir,  nil,-,  ill..,|    in  u  |,li.ii,l.  |  l;i 

',''"  lK-,i,i,r\    Mil, I    tvj.iiii-    1.  iali.iii    l.,iw(...|, 

<  .  r.-l.|-,>-|.ll,:,l    l.v,  1,   H|,l„,i,l    ..,,,,1     ,|llV.'|v|i-  .-,1,1 

li.'ii""  '-'•''  uiili  l^|,lh,i,|.  :::;.■, 
iii.-iiiiii.'iii-  ill  i\  |.li,,i,|    27i) 

t\l.li.iii|  and.  ilittiiviiii.Mii..n    41.;  K,M(    all..ti..ii-    in    ,iiai:ii..-i-    ..I'   u  |,li,,i,| 

11  |.iiii- ami.  .JitV.M'cntial  iliaui,,,-!-.  .ViM  4111, 

Clii.oi,!-  m  ui-iii,..  I,, 111,  ti,, 11  ,,i;  in  Ivpln.i,!.  ,liaiiL"-  in.   in  U1.I111-,  .',41 

I""'  ,li-,a-.-  in  t\|.li'..hl.  L'.-:; 

<  li..l..\-lili-     in     , \al,-,,n,,      li,,n,     n-  in  ,  ,  ,in  ai, -,',  ii,v  iV,.ii,  i  \  pli,  ,i,|,  ,(77 

|'li"i'l.  -M-'i  ill  H|,l;,.i,i.   1L>-J,  4i;'.i 

ill  l\|.li,ii.|.  -.'O'l,  41I7  Kai-tliiii  .•li,il,.i:\   ,,f  i\i,li,,i,l    .-,1 

t'li.,;,  Iitliia-i,  r..ll,.»iii-  tvj.li.ii.l.  L'Ki  Kh.rlh-    La,  illu-,    I'l.'      .S...   al-..    lUinllus 

ill  ...iivali. 111.-  rr,.iii  i\|ili,,i,l,  .!7.',  !',//,/,,,,-,(«. 

«li..|..ra.   .\-iali.'.   willi  t\  I'.li.ii.i.  ;'.L'.".  Kl,  lii,  li  -  ■,lia/.,.-i-,a,  li,,ii  in  t\|.li.iitl.   I!KI 

<'li,.na  ii,ii„.r  in  t>|,li,,i,l.  L'l;;',.  L'WI  KI-iiiT-  111, tli,,,!  i.C  1  \niiiiii»ii,.ii   ,,f  .(,...1- 

t  lir.iiii,'  all'.',  ti.in-  ami  lv|iliii-.  iiliiti.,11  1.,-  4L"J 

tu,-,  II.  .-.i;!  Kini--i in  I\  ),l:i.i,l.   111.', 

<'ii-,iilal,TV  i.rLran-    .liain^i-  in,  in  tvplm-.  Kmi,„iiii|in-  in  H|.|i,,i,|,    Id.'i 

•'-'■'.  iil,.iaii\.     U|.li..i,l   ami.   ilitl'.  ri-iitiHlii.ii. 

.Ii-iv,l.r-  .,t'.  ill  iy|.lh.i,l.   Ii,::  41:! 

in  t\|,li.,i,|.    I.VJ                      .  K|.i-l,.lii-  ill  I\|.li..i,l.   li;i.  L'41 

<l,,|iliaiii  -,li,.,,l.  ,  |,i,|,'ii,i,'  ,,f  t\|,li..,.!  .11,  .-,]  K).i-ia\i-  in  iliau'ii'i-i-  nt'  t,\  plmiil.  406 

('iiiiia!,.,    ..tlri't    ,,!'.  ,,n    t\pli,,i,|    in..r!alil\.  Ki\ -ip.  la-  in  1>  pln.iil.   I  :!(l' 

■>l  in  \\  pliii-.  .'.:;.; 

<'li,|liiiiif  III  .li--.  i,iinati,.ii  ,,f'  l\|,li.ii,l     .",|  wild  Hpl,,.l,|.   ::■.'! 

<'..tf',-,- a-  n  pin, ill  pr,,pliyla.  tir,   17  K-i.p!,aL'n-  in  Upli.'i.l.  L'04.  "JOt; 

<'..M.  .'tt'.,i  ,,r.  ,111  i\pli,,iil  inl',-,  ii,,n.  i;4  p. -i-n,, n  1,  n,  appiaiami',  !il 

<''.iiiiimli\ili-  in  ,|ia.jii,.-i-  ,•!'  typli.i.l     im;  Kii-la,  l,ian  till,,'  in  t,pli,.i,l.   \-Sl 

in  tvpln.i.l.  i;hi;  K\aiiili.ii,iita.     i\pli,',i,l      ami.     .lilt.T.Mitin- 

('■.ii-litiili..ii,    .■IV.-il   ,i!'.    .,11    t\pli,.i.l    iht',,'-  ti,,i,.    41.'i 

li'.ii.  I'.-J  t\pliii-  iin.l,  (iitl'i-nnliiil  '!iHirm'>i^,  r.(i:i 

in  typhii-.  ,ll',.,t  .if.  ."ii;.".  Kyi'  <  haiiiri-  i"  iM'lm-.  '".I'' 

<'..ii!a.ji,,n  lli.,.i-\   ,.|'  |\pli,,i,l.  •_'!  ill  ,-,,nMil,-,, ■!!,,'  tV lyplini,!    :;77 

<', nival, -,■,■11,,    in  tv|.li,.i,|.  471  in  ],r,.:.'n' -i-  ..f  lypliii-.  .Mil 

in  lypliii-,  i;-J7  KmIi.iII  in  lyplmi,!.  ■-'Mi 

p.i-i,..!  ..I'.  ,  .,miiti,.n  ..t',,i-._riin- .liiriiiL'.  "di  K\,-.  ,|i-i:i-,-  ..I',  in  I\pli,,i,|,  ■js.'i 

in  lypliii-.  ."iii'.i  in  typlii.i.l.  p,r-i-ni.,it, ppi-anuicc.  12'J 

<'iir\/ii  ill  ilia'_'ii..-i-  .,t'  txpln  i'l.    Im; 

<'ninial  h.tv,-  in  l\pli.,i,l.  L'77  K  \  r  1  kikhk.h.  .'.•'^1 

Cn  p|,.Lr.ni,'       -,  pii,  ,.jn  ,iiiia      ,litV.  n.niial  K,l.ii-     .■a-tnn-i-     pii,',liiali-    ,.f    Ivpliu? 

.lia'j-'i'.-i-    t'l',,111    l\pllll-.    .■||i7  .'..'^7 

('ilta.j.'i.u-  al.-<  .--  in  lypliii-.  .'jli.'!  ,xnii!  li.niali.a  ^iIll■  .■xalltllclliato,  .Wl 

<'\-titi-  in  tyi.li..i.l.  lli.'  ,if  typhus,  5'jy 


^ 

^ 


» 


► 


fM>i:x. 


637 


KfhrU  mititicu  r.f  tv|iliii.    .'.sa 

vr«iitili-,  'Ji.t 
Ki'ci'..  K,i,  illii,  li  |,|i,„i|.  III.  ;i-j 
\  il:ilit\ .  .!7 


Hcirt^n-Siiiitli    liMll,.„i   .,r  iirin.-   .Niiliilini- 

tii.ii.  4L'o 
IImu-.  Ii.,|,|    arlirli.     in     lii--.  iiiii,:iii,,n     ,,|- 
lv|.li..iil.  .VI 
,  ll>.|n.lh.n,|,v   in  l\i,li..i.|.    1,1 

l-iliml.-      J.lillall:!,     .\l.lli;il.     III      H|,|i,,i.|,  ih  IV  plm-.   i.l'i 

'''■  ,  llv|..i|.M,li,.  ,1,.,..  ,,f  ni.liii-,  .-,:,; 

clmn^.  -  in,  in  |\  pliii-    .Viii 

^,       '"  tM'l'-"l.    !■".      "  I.  iKi-.i  >  ill  iv|,li,|.    .-..;,; 

[.'■""'™'  '[■'"  ,'"  '.M'l'""l     !'■■'  iM.li.i.n  u,  m-Mi..  in  Iv,,l,..i,|,   \K> 

i-<-(n<.  ty|.li..i,|  i,i|.,||,,„  .,|-.  1,1  Ihf.iilil..  r.,i,ii|,.nl  f.'.Mi-    ;!:1| 

H  ilMnn.u-  pn-iiiiinnii,  „i,.|  |,  ,,|ii,.    ,..|:,ii,,r,     lut\n.-n,,,.  Is  ,,|,..i,l  „i„|.  ,iiir..n.ntMli..n.  4M 

,.  I"tw..ii,    .1,.:  Iii..,iil;iii I  iiniiiml-  vwili  Ui.li.i.l    .;ii 

■.'""''■''"''"'■""■■■-'•  Iii«aiiilv,  tvi.ln.i.l  mill    L'll.s 

'•"""" '',-"".M'l'"i'l.   1-"  |I.il.--lnial„nli...|.-i-,  ,.|,1,,„mI  ,n     III 

'"  '.M''"i-    ■•■-  '  ill  tM.l...i.|,    111 

i"'""i'"iii','".    L'l:       s..-    III-..   ,s/,,„/, 

<i.u,l.-iii.  M.UKU     in     r..n\.ii, ■-,■,. nc-i-      iVom  /</,»«/„. 

l>|ili..i.l.    :;;.-,  in  ,lia:;,i,;.is  ..ItviiliMi,!,  4011 

,.',';',''"'"'■■-''      ,  .  '"I"---' i^uft\,l,.,i,l,  :!,.:! 

(.aM-t..n,..  1,1  ,.,, rival,. ,,■,•11,. ■  liMiu  iy|ili..hl,  in  H|.li..i,l.  HT,  -i,,:, 

,       ,     .■'",'      n-         ,       ,  l..ir..r,ili..ii  in  U|.|i,,i,|,  4,,.; 

,.'>!'' I'"'"ll'-";l    ,-'!:'  Ini.-liiH..  ,„.a,ii,;„i„„,,r.  in  ,v,.li,.i,l    ;,7 

'•""-'■•"',  ""^ '''""■'.'    ';•'  '"'.M i.l.  |".-.-.n..r|..|ii„,i,...'„:iii...    .,1 

-|-iitaii...,i-.    ,,l     til.,     .vtr.. I....     in  inv  .,|„|i,.,i   ,.f  ,n,.,liil|,„-v  -«.  Hi, li,, 

.     ,  .  'M'l I.    I'M  Iw i,|    ..,1 

■■<    -kin.n,v|.|„,i,|,    |;-J  n,.,.r,,.i:,,r,   in  ,v,,l„.i,|.  I,:, 

""■;-"."""•: "Mr,n|,li.,i.|    -.'U  •        ,ii,..r.„r,  i„,v,,i;,.i.|,  ;m;    .,m 

:"■"■"■,:'""■'■•  ' 'II"- '.M'l':';" I.  ■'          In. .-tin...  ill  ,.r.Jn...i-.,r,^,,l„,i,|   :;;i2 

'■■■nit.l    h„i,.u„,i-    in    ,.,,iiM,|,..,„i„,.    ,v,„„     lnn,xi,„,i,,i,-.  ,v|,l„,i,|i,n,l    ;;-'^ 

,,      .,        'M I.    -«  .lill-.n.„ti,i.i„n,  411 

l>.nil..-iinii:irv   .n-ixiin-,  .  Iian:;.-   in,  m    t\- 

■     '''"',"■:'/'',     ,  •'aiM'I.  t  in  ,iia..'n,,.i.  ,.rn|,li,,„l,   II,.; 

f.liin,!-,-.    „i„|    ix,,l„,i,|.    ,lii|-.ivnii„|    .Im^,.  ,„t,.nl,:il     -o: 

li'-i-.  HH  ,,„i,.  ._,,,:, 

Mini  lv|,l,i,..  ,|iir..,vi„i.,|  ,li..,^,„,„i,.  ,,„:;         .r,.int-  in  , m,|,.-,.,.„,.,.  ,>..,n  tvpli,.,!    :;7K 

::::::':;;::;,!:;;:;■;;:-'•:;;:;::,■  ::;i,:!^'4.;  ^;::-^;,:-ri'^;"-'"- '^ '■""■■'■  ■^■" 

II  ,     .  ,     .  Kniinv-,  ili.ii.M-,-^  in    ill  uiilm,    .",i(i 

ll.iiiiliiirL,'  H|,li,,i,|  u-\,r  I  |ii,|. mi,.,  41  ' 

lliiii,!  .|i-iiif..,ti,,,i  in  U|,|i,,i,|    4;i 

H.-..,lii,li,.jn   (■.,iiM,l.-,...n,,.  IV t.v|.li..i.l,     I.\.Tvii,,N, 

i,'"'-^',''"''''  -""        ,         -,-  L„.t..|,ln.',',i„   i„tv,.l,„i,l,    1,;:; 

" lii,|.-,.  ,ntv,,l,„i,l.   1,;,-.  r.„rVnu'...v,,liM,l    -I.-,  ' 

in, ■,.ny,il,.-,. .,,,...  l,-..,i,  iv,,|„,i,|.  :;:;;  |,„nnN.  .Imnu'.-  in,  in  tvplin-    :,1 1 

'"'■^';'"'"V"'-"'""^""'I ■■■■"'  '"■ :il.--....    IV ,!,,l,„i,l     ;:.; 

iiiii-.-l.'  in  lvpli.,i.l,  l.-,:i  , ,■  '    ,.     ',  ,,., 

■:'iv-i-„n'.i„,,,,.,i  ,,,.ii„i  ;„,,,,,,„;,,   n,r;:!i'';;i-'i::',:;;nr  ■:;;>''■' 

l{:::;;:^;.Ti;,';;;^/.'!:;r!n;;;.,i„i,,.,:.     '---u,,, ..,,...!,,,.,, ,,^,,,05 

in  ...nval,.,,.,.,,..,,  fn.n,  ,v,,li,,i,|.  :;,;:  |.i    .  i,,' ,v,,|,:.i,|;"i.,,i 

II.M,„.n-l,:,:,i,.  .■a=,.s  ..t  ..,|,1,„-.  r.si  |„  ,.„,|,„i..„.,. ,|.,;,,    ui.l  ..i,|    :;7.-, 

|.l|.'n,.nn.nau,  pn.L'r„,-,>.,rtypli,|..  .-,;rj          i„tv|.l„,i,|    -oi;  ■' 

in'u     l"'-  1';  '""/'I:'"-   •■''-  1''-'- ■■t..,ii  a|,,...a,-an,.,.,    I„l 


|...-t-Mi..|-|,-Mi  a|,|..iiraii.  .■.   11(1 

I'M'.-.'I  .rl'ty  |.|i,,i,|  inl', ,  h,.ii  ..II, 


I 


f 


■-■^.i 


^ 


i;;;m 


.11,!  , 


^:-?'^'' 


Luiiif.  ul»<-.-..  .,(•,  in  U|.li..i,|   -,i 
ifiiiiirniH- ..(•,  ill  l>|i|i,,i<l,  s,:, 
Iwri'iii'lM iiiM.  iliwi 

Li 


N'i-"|.liiir\i,,  ill  n,,|i..i,|,  a.ts 
Null-.,,  In  |^.,||,,i,l    .jm 


|.li..|,|.  117  ■•   Ml  iw    -^-'plinii'ii,  „|„„tH.,  ,,^,|„.„,    .„^, 

li>|»»luii..„iii;...ii,,„,,,-  i„  ,.,,i„.:,  ...^       I"  l"""'.'ii'»i- Ml  H|,l,..i,|,  :i:n 

i:;i:;'r:wr,;r;»;^!:;r  -■ .;;£;!;;'.■..-„.. 

Lv.M,,i.-«iumi., ,.1.1.,,,., i„, i„ ,.,.,,„.. -.,.  ^;^;;:;;'^!^;'"-  '^ i' 


liinili |-  ,.|,„.,    1,,^ 

I'l  I, ml.  ,;,; 


Mu  \i(u  ,,i„i  iv|,|i,,i,|  f,.,,.r,  li.-, 
t,\(ili..i,l  i.ikI.  iliM'i  ,-.  ,iii„t|..|,    ji  J 
Willi  l\  Jill. .1,1.  :!ji| 
M..l»rl„ri..,,.p  „,„|  ,,,,1,,,,.  ,1„|,  r.  nl,;,|  ,||. 

iii;i,ini>,  iViT 
Mul.;  u'-Mil,.li«,  ,.|,„„^„,.  ,„    i„  ,!,,,_    ..^1, 

111  l>|,li..i<l.  1 1)4 
.Miini-iini«  ill  |(  i,i,,,i,|    -Jill 

xl'T'r,""'!'! '■''''"■'''  '''"''■"•'"i"'""'.  ^1.'' 

.^l--.l,lU„   ..|.|.,„i;„|„    1,1    H|,||,,i,|     ._.;,j 

l"'^t-ii,ori,.,i,  ii|.|MMriii,i  ,.    I-.'l 
Mfiiitii:..,,!  li,.ii„,rrli:,i:"  ill  l\|.li.,i,l    •'::! 
*'••'""-"•••  <"r.'l.>-Ml.  i„   tvpli.li.l,  ,..„i.„„.,-- 

ti'ii,  iippi'iin,, I  |., 

ill  tvpli.iiil.  •.',;;( 

Mriiiiifitl,,  ,..T.I,r,.,.pi„„|.  i„   ,v^ 
••pi,li.,i,l|.    (■|.n.l,r..-piiii,|.     H|,|'„,|,|  ",,'„'| 

<litl'i-n.iitiati..ii.  •_'i;!i 
ill  i>pli"i''-  lH'.  'J>''' 

,,i!iiiili-t.ili..ii  of.  I'T^' 
tiil.i.rcii|,„iv  i,,  uplii.iii    -j;;; 
t,vpl,..i,|  Miul,  .Iiin.n.|,ii,„i,„i     112 
.M>.,,,i,^.mH  p||,.i,|     ,;|,, 

■^''•"-"•"■'ll"li        i H„l 

typli..i.|    :;:ii 
in  t\  pli.iiil.    I'li; 

JI-  -  llt.'li,-  -l:,,i.|-  1,1   Ivph.  i.l      IIHI 

•M.I.   .ris,,,  in  ,,|.,,.|„„i;  ,,!■,,. ,1,11,    .v,- 

111    tipl|..i,|.    J|;_.      ,,;.- 

'Iiliii-ia.  :A-,;,lli,,;,  |„,|i,,,,,, 
Hi  I 

ill    I\  pl|,,i,|.    ijs 

ill  n  pliii-.  .■,:;■_■ 
Milian  ■|-il„.r,.„|,,-i.    ,„„|    ,^..i,,i. 


■•iii|ii.l,  ;iiL' 

MT-iilil...    .'ML' 
•.»-l;in.  (•limii;,..  in    i,i  l\p|,,i,,  ,r,;t4 
■li-..nl.T>,,,C.  in  H|,|„,i,|     „;,, 

ilM"l,Mll«..<.|„;-,.  In, 1,1   Up|„,j,|     ;J7,., 
Ill  |>n.i;ii,>,i.  ,,(•  Ivpl,,,.  ',V,| 
ill  l,vpli..iil.  S.:! 

l".-l-„H.rl,M,  iipp,.,, 
in  tv  i.l,,i.,  .-.li;,  ,,;_/) 
|»-npli..r„|.    i„    t\pl,..i.| 

»p|"il,-,i,ici..  ']-j-j 
t"\iii-  II, mI.  in  np|i,,|,|    -jij, 
Niiir,ili.-i,i  ill  t\i.l,i.i,|,  L'Hi; 
.N'l'iiriti-  in   l\pli..i,l    ..Ml 


I".  ,    MM 
p"-l-,n..l'I,.i|| 


VfJ 


l...|u, 


N.'iiia  ill  npl,,,iil,   I.;. 

ii,  lspii,i~,  :,:■:; 
}■''■'}•>■  -'Til    N..-.',l„i„:;,..  ii,.  ,„  ,,.,1 

IM  Hpli..i.|.  !>:> 
NVuri'ti...  ,,p,i,     i,,  U|,|,,„|    ._,yt- 
>>>iir <  in  t\  |,|i,.i,|.  -jMi 

"111  ,11  I  I-  in  iv  |,i,,,i,|     |.,| 
•'-t.'.nn.iili-.'ivpli.i.l  ,,,  ,1    S!) 
•Iilf.r.nliiini.n.  41) 
In. I, I     (i-iiii-.  H|,|„.i,|  ,-,.v.,:,,mI,  s,i 

''^""^^^■•'"".M'l""l.|-i- ,t,.i„  „,,,„.„. 

Jill.  !■,    Ill;;  '  ' 

l*:i,i,l\-i.  ,|._rii.-,i,.  in  ,,  ,,i,.,|,|    -j^, 
ill    I\pli..,.l    L'77       ' 
'  'M'li"i'l.         ,i..,i,'iii,..  in  H|,||,.i,|    -jHi 

.'I'  ...  iiliir  ,11,1-,  I.  ,  in  up||,.i,|     2Hr, 
-pn.iii.  Ill  lvi,|i,,i,|.  '^-u 
l".inipl.--i,i  ..f  1,.^-  in  |,|,|„.|,|    .,,s| 


Milk  i„  .Ii-,ii,ii,:,ti,,i,  ,,,■  ,w,|,.,i,j     I.-, 

i,,o,l.-  uf  i,ii;.,.|i,,,,  ,,,'    (,, 
Mitnil  iiiMilli,  i,„,i   in  t\pl>..i,|    \i.:. 


i-'l^iti..,!     I|ar  ivphliii-  in  n  pl„,i,|    -j.], 


M 


■  niipi,.^,,..,  in  tvpli,,i,|    -j: 


M..rpl,iiii,„i.  tvpl„,i,|  iin.V  ;;l'm 
•»I",-tiil,ty  ..f  l\pli,,i,i  .,;«) 

"I'  l\  [il,,i-.  .",m;J 
^I..iilli  ,11  l\i.l,..i,|     I'l-i 
M       ■  ' 


''■■"■■  -I-      I;,,   i;,l      in    Hpl,.,|,|,    ■_;-- 

l';ii-..|i.i  -l.in.l  in  l\pli..i,|.  l'ii-j 
l'.'n'..'ili-  In   IV  |, In, ill    jii^i 

'"'■11 |.  - I-.   L'i", 

I'l'iiiiuilili-  in  l\pli..i,|     III,;     ii;:| 
IVii.  In.n.lriiir   ,1,.,.,.  in  ivp|„,i,|.  242 
I  .  11.  Ii..ii.|iit,-  i,,  IV  pli,,i,|.   1 1:;    -jiO 

l''li.-ll!i..    IVpl„,i,i    |-,.\,.,-„i„|.'si', 

!'•  npli.iiil  11,  IX,.,  ,1,  |v|,|i.,|,|.  jv. 


■N-iMr.:iiM,l,-..,n...|i-,„n,v„l,.,i-    -s      '  '""";•■"  .""';•-  '  I'   Kpl...,'l,   JMI 


■M.v.lili-   in  typli..i,i,  ■_■> 
My'iriinliti,  in  u,,l|,,i,|     111- 

lii-t..rv.  li;:! 

-vinpt..iii,     1,;,) 


.\;.. 


ui.-  Ill  Up!,. ,1,1     |.;-j 


:i^  ll.v    111  l\  ph., ill.    I  ).' 


in  l\pli..i.|. 

in  .liil.lli,,,.,!,  :;:;:; 
p'ri'.iiitiv,..  -J-Ji; 

iiL"'  Mini.  L'.Jii 

.Mil-.-,   -'LN 

'  li;,r':i,  t-i-  . .!'  ,,i„,n in.r    2'2H 

'ii:,i:ii.,-i-.  .-ii.K,  2:1-1"    '~ 

fr.'i|ii,,n,,v .  -j'J''! 


/\/'/  A 
l--ri<..„iti.,,    l».r[;,r,U*..,    ...    d,,.^, ,      ,.    ,, 

t.V|>llol.|,    4)01 

ill  ty|ili'.ii|,  ;»«;,  u« 
•••Ht  i.r'.  i;j7 

«•!  Mini,  •j.io 
•,Mll|>t.iMl»,    SM 

tlirj.-  of,  l'v;m 


•;.;!» 


tn^iiir    fii,  ..|„.r„iu,..  i;;i,-, 
I  '•rilvp'i    I,    I,,  i,|,li,,i,|,  ;;.;,; 
t.Ml'i;.      Ml.  .liir.nMtiiiti.,,,.  40H 


'•  I"  'X.I...1.1   iM  ,^,.^..  ,,|-  .„i„„,r,„ui 

•iii|MTuliir-.  I.',; 
prMir,i,,.tic  \ului'.   l.iM 
ri'l'Ml     i.V) 
I'lirpiin.  M,n..|..„,.  .-,h|    .-,.„; 

'■""■■■'/".""■I I >•>  "I   U|.lh.i,|.  -JO 

'lun.l  l..w.r,  l„.„„,rrl,«u'i,-    ;l|;i 


'■■■'  n,  li|,l„,|,|.    |;,| 


i;''ti.r,k.,r.T.  111..,,,.  ,.,•  „|,i,„„|  .,,  -,.       ,';,'"";"■ ';  "•  '.M'l-  -.1 

•Vl-  (""■■'"•"  in   lw,l,..,.|.   '..;    .,-,  "  .-r„,.,|,..       liial,.„i.i,o;      fiolii 

"'    ■••    -  I  ■  •'  (\  |p|i..i.|     ,;i,7 

ill  I\|>li..i,|,    |7i) 
i:.-ll.\...,  .,.„„, rv.  in  H|,li,,i,),  ;!h:; 
'"■'■'] Ill  l\|ili..i.|.    171 


'''■'"■• '•l.»-'i.-iii'-<>ili"n..f  ,,„,„,., ,,,,„ 

41.M 
I't.'irt'iT  ~  j.lii-M,,ii„ri,i.  1"! 
I'liarviix  in  U|,li.,i,|    jtH, 

I'hi-Mu.rtii,    j„    n,,|,,,,,|       ,,,., 

I'lil'I'ili-  ill  U|.li..h|     |ii7     I,,., 

i;iil.-::.nu-iaMll..  ,|„|,.„.  ,„,^,,l,..,.|,    I,,, 

'"'-"'■'"'"""■I     "I     VM'I'-l.      |"-I-, „..,■,,.„, 
.■i|.|..„nin.,,    II;, 

riiii|iii-s  iriiiiiv..-.,  '.i.i 

<Jiin>".  in; 
I'li'iim.  ,|i.,.„.,..  ,,C,  i„  ,>|,),„,    .-,,,- 
I  l';iin-v  III  .,n.-i,.„i.  ,,i    n,,|,.,„|    ;j,,, 

III  Ujili.,!,).  117,  -j:-  ■     ■  ' 

'litliniitial  .|iii-ii,,.i-     iiM 
rl'Mn.U|.li..|,|,  :i|H  .     l"-l-iii"il'iii  :i|.|..,inii,,  ,.     n.j 

i'ii.Miiii..Mi„ in |„.„^„„.i.. „■,.,, i,„„i ;;,,;,    i;,,,'';,';/;'"'-- :'-" 

III  lv|,l|..;,|.    II,-,  ■'  >   Iin.illi. rrliiii;..-  11,  n,,|,,,|,|    .,,,. 

l'lMin,;,l,-„,,,i„lM,,l,„..  ,,.h,|„„    |„.,„,, 


111  t\  |>Ihi.    .,.,) 

''■'^'i'-'"^  '■-^^'"•|  'M'' 1.  .ii(ii.ivi„i„i 

'Ii.i4ii'-i-     117 
'""I  'M'iiii-.  'Iill-ni.llal.li,,;,,,,,,,,    ,-,.„; 
I'  l:ill"ll    I).  I\i,.,.||_    ,-,,,.; 
Iti'iial  l\  jiliii-,  .'i.mi 

"•"'"'■''■;'■;:;"- "-  ■  i"'"^-  in.  m  ty,.iu„, 

ili-i'u-..-  ,,i;  in  ti  |,||,,j,|  j,,^ 
in  |pr..i;n.,-i-  ..|H,,|,,,,  .v,, 
in   t\|,li..|,|,    _.;;s 


,  .iii..;.i.  II,- 

Kl..;rtlr-   l.ii.  lllll-  :,ii.|     L'-,| 


.■..,| 


llln-iiMii-,  -M'.i 
liv  j.M-iiiii,.    2l:i 

loli.ir.   L'1'1 

-ll<lll.\  l(l(.,„ ,  i,     -^l.-J 

tv|il!'.iV;iiM'l"'|im:;vni,:,|,|..,.-|„„i.     ,,S        ,.'"  V'"";    ''"' 


"■.-'"I"-   I'a.  illu-  H|,|„..ii-  in     17.-, 
in  .li-a-.-  II,, I  H|,|,,,i,).    |o,; 

I'.  I>|.li..i.l.    IJI.-   S,.,.al-.,   7-v.A,,;,/ ,>,.,.,. 
■■'.s,,.l,i  ..,. 


,'"■""    '"li"i:i\   in  tv,,|,.,l,|,  -J.-.N  l;,,-,.- 


I'|H'III||,.U|,||..|,|,      II 

|in-n,.-i-,  .I'l:; 
l'"i>aitlirin-.     l-li,.|iinal 


I'liMi.l.    r.': 


:I7 


I'"'-  in  .il-rin,.  U),|,i|..  .-„■,., 

Ii"tll,.|ll     Ullh     li  |,|,,,j,|      ;;jj 


'^''''■■'■'      -^ --' l-in,.,l.....l.,i..-t- ti.iii 

l'r.L;iiaii,v   an.l  n,,|,.,i,|    ,,  |  ,,i,„,  ,,,■    i ,,-  ^      ,           ■iM"'.ii-iiii'-.  '.m 

...r.,.,,,,.  „n    M|,li„i,|in,-„,,    „'       ■    "■  ^■•H;"V"i-,.|niiiu,,|,„i,|,    ,7,, 

in  iM.li,,-,  .-,.-,1                              "■    ''  >'.iHalina    ami    ,^,,|,„.,    ,|i,i;  |.,.n,i:,|    ,||.,„ 

l'n.-n,,.i>  ,,(■  tv|,liii.    :,s:\  ^               .'"-'-■    '■"- 

[•'•••|.li>la\i,„i'  tvphii-,  iliit  ■  '■■■"■'"'  '';;■;■  l.^l'li-nl  an,i.  ,litlrivniiaii,,„ 

I  -lll|..|||aill,,|lt.,  ,,|-    1,;„.|||,|,   iv, ,)„„,,        .,,.  .       ^'" 

l\v.-li......  ill  , villi, ,1,1    ■.,'   ,      'M"''-'!-    Ji,  ,^,,1,  ,,|,,,„,,|     ...,^ 

lir.i.'li,,~i>' "UN  >'iill.a  III  l\|,|i,,j,|     jsj 

'■"■■'■'■"•';:;"' '■""""■ .m Min.;.,.ti.,i,.  s.!':!:;:":,;'::;';'!. ";  'p'^r:\  -• 

nl  n,.n,,i  ,,,,,, „n,,|„,„|  „„.,,,, 11,^    .jj^^ 

'  "'""■"■■"■.V   .■inl...|i-in    in    u,,|i.,i,l    „„|.1.|,  <'"'■'"■'■"'■■"  Ol'in'i'l  in|-i-.-li..ii. '7:! 

'I'.'.thlV,,,,,    .;:is      ■'  ■     '"'*'   "     "'I""'    I"-'"- -    Mini    Upliu-.  r,.lati„ii    I,,.. 

iraiiLrri'iii'  ill  tv|,li,.i,|    ■!■,-,  .                 twi'Mi,  .'.i;:; 

in/anti,,ii  i„  i^  |,li,  ,i,|, 'Li--  >'rli.-nii,i  in  |v,,li,.i,l,  ,  ..|vl,r,,.,,ii„|    m,.,,- 

tiil.i,|-,Mil,,,i^  in  nt,|„,i,|    -KM  ,       ,     ."lu-ili-  Willi.  L'7.i 

I'lil-i' .■liaii-c...  ill  i\|,|,,|,    -."i  ^    -^    I  ■■■ii'i.  iliri'.ivniiaii,,„    .ji.-. 

ili'-i'-li.v   ill  tv|.li;,i,|     l.-,4  "  NTiini-tn.atni..nt  ,.f  H|,|i,,i,|    441, 

in  l^j.ln.i.l,  l.VJ  ■^".''  '■"•■;■'  "I.  "ii  t^|,li,,id  ii.f,.rti.,i,    ,-,.( 

•Ii.i'.i,-lir  Mil,,,..   |.-,M  '"  'M'!-"i-.   I'"i 

in  ..,iiM,l,.v,.,.„,.,.    1.-7  N,  k-l....l  III  H|,| 1.   IK 

in  .|,f.,|-v.,  ,.,.|||    .,;,^,,.      |.-^, 


jSick.r„„i„.^_,„.,-aii^,.n„.nt    ..f.     in    tvpli,.i,i, 


p^fe^ 


t-T      -'t^ 


«|H>: 


640 


iMit:x. 


Sirk-i ■li-iiil'.'cti..n  "f.  in  ivplii.id,  4.T7 

Skin,  aiic>llH-i:i  la'.  III   U|ilii'ic|,  i;sl 
rliiui:;.--  III.  in  t\|iliii-.  .M;7.  HIIT 

i;;ci;^rii I',  in  \\  |ilh>|i|.    |;i:.' 

in  ri.MMilr..  I'liii'  Ir.iui  typliniil,  ;i79 

in  |ir..';h'-i-  •■<'  l\  |.liii-.  .'.'.i^ 

in  l\|iii.'ii|.  ■■<:;.  IL'I.    li.'i 

in  l_\  pliii-.  .  !      il;i'-  in.  -"'-T,  i;:;7 

Siiciiil  riilnilli.'n-  ill   I^    jilr.l-.    I'.Hi 

-iiii.'.  ■If.  .1  ..l'.  on  lv|.li.ii(l  iiil'.-.ii.in,  I'.'J 
S.mI  III  i:tlMl.'i;_v  ..t'  t\|',li..hl.     .1 
S|n-rial  !*»'n^i'>.  ciiun::'*--  in.  in  ivpliiis.  .'ill! 
S[iiniil  I'.iril  ill  ty|iliniil.  L'7h 

|io>i-iiiMrIi-in  ii|.|"':iriirH  c.    IJI 
(•iiriily>i-  ill  l\  |ilioic|.  ■;7'.i 
|iiin<'tiiri'  in  imninniti-  in  !\|.lii'iil.  i;71 
Spii-i-n.  Imcillii-  t>|ilin.ii,-  ill.   lo'.i 
rliiiiiiXt'S  in  i\  |itiii-.  .'t'Jtj 
cnliiririTiiiMil  111.  17ii 

iil-.^ni I'.  17V 

.  I-I1I1-I-.    !7x 
ilinnni-InitiMn  .if.   IHO 
eiirl\,    17;i 

tiirt i-iii  ill,  1"^:; 

pnl|ialiii|i   ill,    I'-l 
[»-riii'-i'iit  in,   ls"j 
limtni.-li-.l.   17:i 
ri'ilufiiiiii  III',   1  7't 

-iil.-i.l.i f,  :;4i'   :'..'i4 

lirnnirrlniL'i' in,  in  l\|iliiiii|,   I8L' 
in  iliiiu'iiii-i-  'if  ty|iliiiiil,  4111) 
inliinl-  111',  ill  l\|ili.ii.i     IM'J 
in  t>|iliiiii|.   17n 
('\;iiniii:iliii'i,   Isn 
jH.^!-iii..ri.  Ill  ii|.|i.';(r,inr.-,  |(I7 
jinn,  lull-  i.r.  in  i\  |ili.iiil,  ASJ 
S|.iililn.,  .Ii-iiil'r.ii,.ii  .il',   in  I\  |iliiii.l.  -i:' 

^l iii'li,  ilil.'ilaliiili  .if,   in   l\|ilh.i.l.   .in; 

.li-.i;i-i-.  n  |.li..i.l  inf. .  liiiii  nil. I    i,i; 
ill  ty|ihii,  I,  2(M 

iiii-l-lniirlilii  ii|i|ii:ii:.ni  .■    ^'l 
Sti"i|».  M.i.i.K.  in   U|i!i..i.l    -.'17 
.111--'  •-'!>•    L'l',i,  'JL'l 
fr.i|lli-ji.  \ ,  L'Lli 
iniiiiif.-liiti.in-  i.f.  -J-J] 
Mi.irtiililv,  L'-J( 
|iriiL'n..-i-,  "Jl'l 
t.ini.iTnliir.-.  Ill  ( .-  in,  L'23 
i.i  l>pli.ii.|,  '.'It 
|i<ii— ..ii|i.  "Jl'i 
Siniinili-.  tvpli..i.l,  I,*-:; 
Sliipiil  11. TV  ..11-  f.  i.i',  :;i-_' 
Siil.l'.liril.'.n-. -..f  Ivplii  -,  r-i, 
.•^n.liiiiiin;!  ill  ;ili.ini\.-  u  |.li..i,f  :'.ni 

Swi  alili'..'     ill    .|i:ii_'|;i.-i-    iif    lV|.||iii.i,    4|iri 

Tm  III.  ri.-.'i'  Iii|iliiii!iiiri-.  1'JI 
'I'l:!   I-  n  plh.i.l  pr.ipli\  luilii',  47 

in  lil.i.i,lv  -i....|-.if  upli.i.f  ■^■s-: 

T..inp.niliin'    in    t\pli.iii|.   .  .  r.  fril    i\  niji- 

t.iir.-  iiinl,  '-'I'll 
T.'iii|».nilMr<'-iiir\ .      in     iilinriiM     Ivpli.'i.l. 

•J'.il 
TlivPiiil  .jhin.l  ill  H|.li    i.f   l-:j 
Ttivn.i.liii-  III  U|i!iiiiif    \sl  I 

T..ii-ii..  in  tvpfiiii!     I!«;i  I 


'r.inL,'ii(    il,   upliiii.l.   p.>st-iii.irt<'in    iippesr- 

1111      ,    '.HI 

'I'liii-il-  in  Ivpliniil,  L.'nl 
'I'.ixin-lvph.ii.i  I'.iMT,  lid;') 
'I'lllilli'll  III  l\  pli.iiil,   L'|.') 

p..-t-iii  irlriii  app.aniniic,  1 14 
'I'l-i.  li..il.iMn.  Iiili-  ill  lypliii',  ^4.1 
'I'll.  Iiiii.i.-i-,  I\  pli.iiil,  ililf.i-.nlial  iliiiL'iiiisif 

4is  ' 
'rri-iiiii-  III  1;.  pli.ii.f  L'i'.4 

'I'llf.  r.  Ili.i-i-.  anili     iiiiliar\,    lyplmiil    llii.l, 
ilitf.i-.lilialiiiii,    llll 
piiliii..iiar\,  in  1\  |-li..iil,   1  Is 
l.\pli.ii.l  iinif  ii'. 
'riili.iviil.iii,  ill-, a-.-  ..f  tiiiiu-  Mild  typlnis, 

nliili.iii    |i.  l\\i .  !!,  .'ii;." 
Typli'    .  |iipliy-iiii-.i.  4  I  1 
Typlii-ali.iii  a  p.lilr  .In-..  :,i)\ 
Tvpli.'i.l  fa.  illiiiia,   I:mi 
'fi-v.r,   17 

iili.|.iiii.-n  in,  84 

llll.liilllilial    plllplltinll    ill,    'J14 

alinrliM',  'J',!:; 

Iir.iii.-liili-  in,  :;iiL' 

i'.iii\al.-i.iii-.i.  :;il2 

r. niisii  .if.  L'!!;! 

(Iiin:ii.i-iv  4U7 

iinplii-ili-  in,  :'.00 

p'Tiliinili-  ill,  :i(i"J 

ri'lap-i--  in,  :',(i.; 

syiiipl.iiii,-.  :;ii| 

tiMiipiT!iliir.-.iir\     in,  2li4 
nli-.i  -^.■-  ill,  |:;(i 
ai'cliitiali/Hti.iii  aiut.  7'i 
aiiil.i  cixaiilli.iiiutii  anil,  ll'Jl 

inf.i'li.iii-  .|i-i'ii-cs  witli,  ;;•_':! 
aih  nanii.',  •'>]'■'> 
ufffrii.  ,  :'iii;i 

iliiii;iii.-i-,    |ii7 
utfiilinii-  I.f  Kiilin  \-  in,    17(1 
iifli  r-fi'ViT  III',  ;:.'.'.i  ' 
iiir  ill  lran-nii--ii  11  .if.  4;t 
ulliuniiniiria  in.    I  st; 
ul.'.ilinli-ni  an. I.  :'.-J,s 
llllialir.-i-  in.  'J^n 
14llilitllalii|'\  .   :ill". 

llillLMiii-i-.    Ill7 
iU.  1     an;lira\.     .litf.-i-.nlial     .li:l"n.l^i-, 

41S 
mill   iilli.-r  .|i-.a>.-.  r.  lali.m-   Ii.'|\m.ii. 

ii.'i 
a II -ilia  III,   'Jul 
aliin    .1  ili'ii  illalii  <n,   :'•() 
aiillp\  11  ll.i  .liuv-  in.  4i'iO 
iiiilip\  I'iii  in     In'J 
u.irla  ill.   l'."- 
aplia-ia  in.  ■J7  I,  ■J7"i 
appiliti'  ill,  L'li'i 

:in-anL^.iin'iit  ..f  -i.f-i'i'nn.  in,  4-'.t 
aril  rii-  in,   lii7 
art.riti-  in,   lnT 
A-ialir  ili.ij    la   V.  illi,   mL'-'i 
iilaxia  in,  "-'7'' 
alavii'.  :'>!  : 
llla\i.-ailv  naliii.-.   .'IH 
Ittypi.al    \^illl  -li.,rl.  iirl.l  .  .air^r.  '"Xi 


isi>j:x. 


(54F 


Tviilinid   f''V.T  Imcillus.    'JO. 


1  V|)rii'i 

cUlii.i  /y/i/iij,si(.i. 
l„.il-4i.ri-s  ill.   !■!!> 
bill'  in.  lill 
b-.liiirv  i.;i>>aL;i's  ill.  liOtl.  lld'J 

iio^t-iiiiirtorri  iippiuniiicc.  10-i 
bilinii-.  :M1 
blml.liT  in,   |,..»t-in.irt.iii    iipix-urancc, 

1  r.'  I 

M,M.(1  111,  170.      St  nUi'  lilo,,,!.  I 

lil.Hiil-vi-M'ls  ill.   ii'T 

l>iKlv-ti'iii|«'nitiiri>  ill.  ]M 

tioii'i'- ill.  ii..>t-iiHirtiMii  iipii'iiniiice,  89   j 

liriiin  uIp-ii —  iii.  -•■> 

bruiiilii  ill.  -1") 

|i..-t-iiicprti-iii  iippeiinui"'.  11-4 
lirmu'liitis  ill.  L'1'1  _  | 

bruiicliupiiriiiiiniiiii  ill.  -IT 
(•iit:ilili^v  iti.  Jii? 
I'litiirrli  '..f  -iiiulItT  linin.liml  tulies  iii, 

•-Mi; 
ciTi'linil.  -Ui'i 

iiiii:;'-    ill.    po-t-iii'irteiii   sppfiir- 

:iiir."  ll'i 
in'rvr>  ill.  'J77 
ti.<»ue  ill,  ~H 

post-iiiiirti'iii       pi'aniiii'e,  lliO 
V('>»cl-  ill.  -71 
ccn'liiMiiiiilui'iii  ill.   l''"^ 
coreliro-piiiii;    I'.-v.t    ami.    .lillVreiitia- 

ti..ii.  •-"■.'.I 
clil.irids  ..f  mill''  in.  l"-'' 
ch.iliTv^f.li-  in.  -Jil'.i.   Ii;7 
rli.ili'litliia-i-  r..ll..win-.  I'lO 
clioi-i'ii  minor  in.  -li-t.  'J^" 
rlii.inir  ili-i'H-i'-  willi.  :i-7 
ric'atri/.ati-.ii  .it'iiiti  -tin.-  in,  '.)7 
circ  -hit'iry  or^an-  in.  I'l- 
cli'anlitii-'>  "I'  l""l.v  in.  H* 
of  piitii'iit  in.   !:'.x 
of  pliv-iiiaiis  ami  iiiir-r~  in.  4;>8 
I'liiiical  'inM'.tii;ntioii.  4iM 
clotliiiiir  in  i|i"i-iiiiiiulioiinf.  .i-l 
coUap-i-  in.  iMart  ami.  lti''> 
.•oiiipli.alion-,   r.'L' 
<-oiiiiim-ti\ili-  in.  -^'i 
.•oiilat;ioii  tlii'orv  of.  'Jl 
.-oiila'iioii-m-"  of  77 
I'oii.al.'M'.n.r  from.  .'.lii'.  471 
am'iiiia  in.  o''7 
appititr  in.  o7  t 
t.iliarv  pa:-ai;i-~  in.  •!7.j 
t.oiirs  in,  I'm-i 
clioliTV-liti-  ill.  •'■7."i 
rlioli'litliiii-i-  in.  ::7.'> 

I'oUP-t'.    ^'''O 

,|i._;,.-ti\.'  ..i-L'an-  ill,  :i74 
(Uiratioii.  :isil 
I'lir  in,  ■177 
('VI'  in.  ■!77 
i.r„ll-Mailil.T  in,  37'> 
^'all-tom^^  in.  ;!7.") 
jrcnilal  fiiiirtion-  in.  378 
hc'iidai'lii'  in.  ^(77 
houii  in.  :'.7:'' 
lii'ino^'loliiii  111.  ■!'>" 

41 


Si'.'  ul.-o  Hit-    Typlioiil  fcv.T.  convali'^'enci.' 


Hid 


ill,  .17S 
larynx  in.  -''711 
li'u'kocyli-  in.  174 
Inrr  in.  'M'l 
liiiii;s  in.  :'.7ii 
lm■ll^trualioll  in.  ."iTO 
inii-ili's  in,  .'>7k 
m'rvoii>  .-y.-li'in  in,  376 
piilM-  in,  -"'I 
r.'il  I'orpii-rl''^  in.  M'l' 
pkin  in.  '■'>''■> 

ti'inpci-amrc  in.   14(1,  lili'J 
urinary  oix'aii-  in,  ■!7>< 
vi'iious  tliroinlio-i-  ill,  374 
coiivali'Mi'iit  period.  .'^4 
course  of,  .-tleet  of  a^'O  on,  :5:!0 
ett'eet  of  eoii-titution  on,  329 
ell'eel  of  -lA  on     3'.''.' 
\ariation^  in.  -H7 
(  raiiial  nerve-  in.  "^77 
eiitam'ous  am-llie>ia  in,  281 
ev-titi-  in.   1 1- 
d'.a.l  Ko'li.-  in.  4;;7 
d'-atli  in.  can-''  "f.  388 
niarnei'  of  3'.i.'> 
Midilen.  ■Ml' 
lime  of,  ;JK7 
d''. '  nipo-itioii  tlieory  of,  20 
.{.■lip-'iin  in.  -lil 
d.-lii-i  -n-  ill.  -'■'.'» 
dial"-!.-  iiMllilu-  with.  327 
,r,:,^,,„,-i>,  4(10 
a::''   in.    i">* 
lipiiieliin-  in.  4ii.'i 
(  liroiiii-  ili-i'a-i-  and.  40'.( 
eonjnnetiviti-  in.  41") 
eoii'-titiuioiial    il'iioriiialitii^  in,  iO'J 
eory/.a  in.  40i; 
erv'-talliii'-  niiliaiia  in.  41(4 
di;i/.o-reaetion  in.  4ll."i 
ditVer.ntial.  4111 

liaeti'i-ioloirie.  41!t 
ear  atteetion-  in.  4<W> 
epi-ta\i>  in.  41"; 
lii-rpi'lie  '  riiption-  in.  404 

ill   -la-'-  of  d.  terVM-'llee,  40t»     . 

iiile-tiiial  li.inorrliaL'i'  in.  40(1 

jaiimli'''  in.    '"i; 
'lellko'M'-  ill,  40.-1 

ineteori-in  in,  404 

niiv-d  iiifeetion-  in.  408  ') 

perioil  of  oliM'rMitioii  in.  409 

piritoiii!i<  ill.  40i; 

pid-e  ill,   403 

relap-e>  ill.  410 

r.i-eol   11-  e\aiitlii'iii  ill.  404 

-pleeli  in.    lo:'. 

slooN  ill.  403 

swealiiiir  in.  40ii 

|"iiip''ratiir''  in.  402 

vi<eeral  di-onl'i-  in,   407 
diari-liea  in,  21i; 
.lia/,"-raetioii  in,   1''0 
di.t  ill.   4t". 
di^"-ti\.-  orirmi-  in.  1!>9  » 


I    I 


I'.i. 


I,  ,^  i' 


-_\;£-   -.^ ~  3^  -5y.  ■  :      '.^    '  : .. 


l»;- 


f-i".: 


^' 


tojite^ 

t    !■-; 

1 

/.V/'AA'. 


Tyjihoid   fovrr,   di;;rs|ivc  MrL;»n~   in,    |„..,.     T 
iiicirlcMi  a|i|ii-iiriini'i',  ',)() 

(liplitlirriii  Willi,  :i2,-, 

(]i.-.cii.-M-..  ..f  rv,|,in,tiiry  .irpiiii,  In,  •l(i^ 

di.-iiilV,  iiMii  in,  4ii 
(.t'r,„„l  in,  4.'>: 

lit'  lini'ii  in,  .):{7  , 

ul'  >ii-l<-n.oiii  in.  4:!7  i 

lit'  -iHiiiMii  in,  MT  ' 

lit'  wiitiT  in,  MT 

diiMMiliM.-  of  rirrui;iiurv  iirtriiii.s  in,  4i-\i 
i>(  ilini'stivr  iiri,'iin>  in,  ih-i 

of    IllTVlllH  M.-l.'lll    in,    ili'J 

dissi-ininiili(.ii  ,'.f,  4ii 

I'nrlor-  t'i\.i|'ini;,    "i.'i 
drink>  ill,  447 

(liini  in,  pip>i-Mi.irHMn  ii|i|i(noiiicc  11 
dur;iii..n    ,(",  ;;mi 
d,v.-i'ntiTv  wilh,   :i-J.") 
Par  ili.scii'sc-  in,  -JKI 
I'ar  in,  4til< 

oars  in,  |i..-t-in..rtiiii  apiioarancc,  V22 
farlh  in  i-ti..|(.^'v  uf,  T)! 
ciiniciatiiin  in,  .'.(IM 
••inli.iJiMii  in,   li;!l 
i'ini.s.-iiins  ill,   l!i.', 
on<li-iiiii'>  (if.  To 

ondu(„,"i|iiis  anil,  ilitl'i'n'ntiation.  413 
oniliicariliti-  in,   lo:,,   liii;,  lti4 
fpiilnnii's  ni'    7i; 
<'|iii;l.>tti^  in.   Ii:;.  -Jll 
•'pi^la.vi.-  ill.  L'::',! 
fnipti.iii  of,   IL14 

t,vplioiil  rv hi  u,,,i,  127 

orv.'^ipi'la.-.  in,   |:io 
orj.^ipihi.-.  witli,  ;!'J4 
ci>opliiiL,'Us  in,  '.'(11,  oOti 

posl-nioii.  Ill  iippi'iiranop,  91 
t-spi'ciiil  varii'tiis  of,  470 
etiol.iL'.v.   17 

|'o^^lnsion^^,  77 
lii-lorii'  i-oii.i(|(.ralioii.<,  19 
cxiiininatioii  of  stnols  in,  402 
pxanlliiiiiata  anil,  liitl'iTrntiation,  414 
oxtiTiml  iippi'iiniiiii'-,  po~t-inortfin.  Mi 

inli'LTiinii'iit  in,   lL'4 
»'vi'  (Ii-. inlri-^  in,  'J'.i'i 
•'.viliall  in,  :.'m; 

ev  1  in,  piKt-inrirti'in  appranini'i',  122 
fiisliijiiiiii  of,  h2 
fatal  tiTiiiination  in.  :!82 
fi'lirili'  coursr.   l;!:! 
■stjii;..,   Kl 

iliiration,   141! 
fi'iniil..  L'lnilali.-i  in,  190 
lloiiitiiiion  in.  -Ji;.; 
fooil  infi'ctioii  in.  4:54 
fliliMiiiant.  2KH 

iliiH,'iN.~i-.  4(h; 
funinrl,.,  in.   |:;0 
Call-Miiililir  ill,  209 
panirn'm-  in,   1(,7 
of  IM.  Iv  in,  212 
of  -kin  in,  l:!2 
jipiTitain'oii-,  lii7 
gari;oiiii:,.|;i,.nt  in,  214 


,\pli..iil  I'rviT,  ca-tric,  .'ll  1 

Uu-tro-iiitr-tiiial  ralarrli  and,  ti6 
iTi'iirralivi'  or;;iiii-  ill,    194 
i;.  nilo-urinan  oriran-  in,   |H4 
k1iiiiiI.iv,  ililli  ivntial  iliai;noHii    4I8 
^'r..iiiHl-«,.,i,.|-  ami,  2:; 

tlii-on.  .'C 
hair  ill,'  I. '12 
)ii'adar'ii'  in.  2i'iO 

jii-ait  in.  po>i.,„.„.t,.„i  ,i|,j    sranoe,  KM 
lii.ait-niiiM  li-  in.  l.v.i 
lii'iiiiplci;ia  in.  274 
lii'iii.ii,'|..l,iniiria  in,  1H9 
lii.iii.irrliai;i|..  .'A:', 

iiiiii:iio>i-.  407 
liirpi'ti.   .■iiipii..n,  in,  129 
lii-t..r\.   17 
lioini-  trratini'iit.  luirscs  and  R«.sislanU 

III,  4:i') 
liospital  iiifi'iiion.  (;.'! 
lioii-i-lio|,l  anil  !i.,  ill  disReiiiinution  of 

.".4 
li.vilr.itliiTapv  in.  4"i4 
li.vpiTi'iiiia  of  iiiti.>iiiii.  in,  92 
livp.ipyn  lie.  2KH,  .■!l:i 

ili.ii;iio>i..  401; 
Ii.vpoMiilii'  i.oiii,'|.sti.in  of  luiifja  in.  24H 
iniiiiiinitv.  (i7 
in  ni;i.il.  ':{40 
in  rliililliood.  :!:!() 
aliiloiii4.|i  i.i,  .i.'in 
tii'il-Mirrs  in,  :i.!:i 
duration,  :i:i|,  :f:{,', 
fflirili.  >_Miipt..iii,s  ,131 
lii'iirt  ill.  '■'•'.V2 
inti'stini  -  in.  333 
kidiii'v    ill.  3.{4 
iiiorlaliiv,  3311 
nrrvous  .-;  -liiii  in,  334 
l"-riloiiiti.s  ill.  333 
piil-i'-niti-  in.  3.',2 
I'l-lapM-  ill,  :!:',!, 
ri^piratoi-v  atli.cti.ins  in.  :i33 
skin  ill,  .,;12 

spiiial  siiisi'  iiri;an.s  in,  334 
spli.cii  in,  333 
in  infants,  3311 
pi-..:;iio-is,  339 
piil.-|.  in,  339 
skin  in.  339 
spli'i'ii  ill,  339 
stools  ill.  339 
tiiii|Mratiiri-  in.  339 
voiiiitii.i;  ,0.  339 
in  latiM-  lit;     340 
iIiai;no>is.  342 
fi'NiT  in.  3-» 
lii'urt  111.  342 
•nti'-tinrs  in.  342 
kidnivs  in.  343 
prolan. .-is.  343 
puN..  in.  "  ;i 
iTlip.-os  in.  ;;|:i 
n-piratorv  atl'iTtions  in,  842 
skin  in,  313 
spl.'i'n  in,    ■42 


I 


-^^ 


iM>i:.\. 


'AA 


nU 


of. 


!4H 


'l'\  |ilicii.l  ('•■vr.  iMi'iil.Mli"ri  |M-ri..,|,   ,;) 
iiiil  .  .iii  III  urine  111.   Ihii 
iiilr.  Mmii,  ,<]■<:[  ,,(  ai;,.  ,,ii,  :,(; 

i<(  c.lil  ..II,  Cl 

"if   .■•i|l-lilUlii.|l    ..II,    lij 

of   |..l'llti II.   i\\ 

of  iiii.(l|.  i.f  liviii.;  i.n,  ill.' 
of  ..(  rii|intic.ii  1.11,  i',-J 
of  pn'i;niHi(  V  ..II.  t'.l 
of  |.iiiT|.iTiiiin  ..ii.  1,1 

of   -.A    ,.,|.    .Vi 

I.f  -...■i.il  -iiil.'  ..II.  CL' 

"f  -t..iii,-i.li  .li-.-;,.,-v  ..II.  CO 

cxIiTiial  iiillii.  I ~    7(1 

fiii't..r>  fiivi.iiiii;.  .',,1 

(;i-'.'.,'rii|iliii'  iiilliLMici-.  711.  72 

iiiiliv  iiliiiil  iiillii.'iii'i'..  .~>i; 

l.nul  illlllli-llri..-,   711 

iiii.li'iir.ili.uic  iiiiluiii,-,..  7;! 

iii-rv..ii.  (|i-..a>i's  luiii.  i;il 

M'ii-..M  and.  7.'i 

ti'iii|iiraliin'  inlliii'iirc.  7.") 

\M'atlii-i'  .■iml,  7") 

iiillaiiiinati f  lirfii>t,s  in,  11)7 

iiillaiiinial..rv,  :!IM 

inociilati'.n  in.    '.'M 

iii>aiiity  ami.  L'»IH 

iiiti->tiiial  liiriiiiiTlmi.'c  in.  '.t7,  217,  4i;5 

pain  in,  'JI4  | 

piTf.irati.iii  in,  4i;(i 
intistiiii':-  in,  21 1 

po  l-in.irti'Mi  appi'iininci.,  !i| 
iiitoxicaii..M.>  anil,  .'>2,H 

(lirti'n.ntiiiti.iii,  41-i 
irritativM.  :11:! 

jaiuiiliiv  ill,  20«;,      S,-..  aU..  ,/„>im/icf. 
joint-  in.  po<t-iii.irt(iii  app..H.anci',  Hit 
Kidni'V  (li.-ni.-!',.;  in,  1!I4 

p..-1-iii..rliiii  i;ppi-aniiii-i',   li;() 
lui'|..pli.'niM  in,  4'l:! 
Ittryiiiical  iarlila.:<.«  in,  242 

synipt.iiiis  in,  244 

ulocnilii.ti  in,  24ii.  24:! 
liiryiix  in,  2.'!',! 

p. .^I-Mii.rtrin  appi'aianco,   11.3 
Iciikoi  yti>  in,  172 
lip-  ill,   \'M 
livi  r  in,  20(1 

po-t-iii..i-t..|ii  appcaniniM'.   101 
localizati..!!  tlii'orv  ..f  2:< 
lo>s  I.f  wi.ii;lil  in,  iii'iH 
liiiii;  aliMCs-  in,  2.'>4 
Iiinirs    in,     p.ist-iii.irtiMii     appciimiice 

11-. 
nialiiria  anil,  Ii.'),  ;i2ll 

(litliiintiation,  414 
liiali'  i.'1'iiilalia  in    l'<4 
inalii;naiil.  2MH 
nianiMiiiis  in,  2!<l 
iiini-!i.>  iiml,  ilitfiTi'iiliatioii,  41') 
Jiicilulla  i.l.|oni.'atii  in,  27(: 

p..-t-iii..rti-ni  appcanincc.   121 
liii-nin.ji.al  lii'ni..irliat:i.  in,  27:! 
iiii'niiii:i.<  in,   I  Hi.  -Jtlii.     .See  al.oi  Mr,,. 

iin.nini,'iti-,  ill,  .;i)!) 


'I'vplK.iil  fi'viT,  iiirii-truuti..ii  in,  1% 
iiii'M'titiric  lilanil-  in,   1(N) 
iiictcori-iii  in,  212,  4il.-i 
mild,  liiiiprraliiri.  in,  147 
tniliaria  ii\ -tallinii  in,   12H 
milk  and,  4,'i 
inilral  iii-iil!ii  i.nrv  in.   1115 

111 I  .-.^'iu  in,  27ii 

iii..rpliiiii-ni  and,  :(2K 
niLilalilv .  :;k1 

Hi;.-  and,  :!h4 

I'liinalc-  an. I.  :!K4 

,i;i'..!,'rapliii-  ditlVrcnco,  384 

I'ai'ial  inlliii'iiri'  on,  :!M 

."I'a^. .11  an. I.  :iK4 
iMi.|..r  iiiiimfi-tiiti.iii-  ill,  2il2 
nioiitli  in,   lli'.i 
niiir..ii-,  ;il  I 
iiiii-ili-   in.    p..-1-iii..rtciii  iippearaiire, 

iiin-.iil,ir  al.-i-n--  in.  88 
ni\..|ili~  in,  27S 
iii\.irar.liti-  in.   10.') 

Iii-t..n,   lil:i 

-,\  niptoiii-.  lliO 
nails  ill,  1:12 
na-al  cavit.v  in,  113 
niiMipliiirynx  in,  2.'!8 
miUM.ii  in.  204 
ii('(To>i,-  ..f  iiiiotiii.,  in,  ;t5 

..f  laryi.  ^  in,  24  : 
ii'l'liriti-     ill.     111,     r,il.        See    also 

.\.j,/,,-;t:s. 

iiiTv.m^  .-y-ti'iii  in,  2.'i0 

l)ost-iiiortc  111  HppcHrance,  118 
niiinili.'ia  in,  282 
ni'uriti-  in,  2K0 

opti< ,  2H7 
nciin.si.-  in,  280 
iionia  in,  I:12 
nose  in,  2:i8 
iiuivliiir  in,  443 
ol.litcnitin;;  iirti'iitis  in,  1C9 
of  fciiis,  (11 
on  liili-  in,  1!I4 
o^tl'olll^  .liti,  and,  H" 
ditffi-.-nliation,  414 
ostiti-  Mild,  8',i 
otliiT  disi'HM's  with,  ,3;>1 
paniTcio  in,  pi..-t-iiiorlciii  appparanci', 

t(i:t 
pii|iiilar  cxanttioni."  in,  128 
paraly  is  in,  277,      .s;....  I'arnhjxiH. 
pan-is  in,  faiial,  277 
pan.tid  irliiiid  in,  202 
pan.titi-  in,  202 
paili..|..i;v.  7',l 
piTi.anlitis  in,  KXl.  1(13 
piricliondrilii'  al.sci.-s  in    '"2 
poi-iili.. II. Iritis  in,  1 1  ..  24.< 
pori..s|iii.  an  ,,  H!l 
pi'riplii.ml  mrvi's  in,  280 

ii.'iM.iis      >ysii'ni     in.    pi.st.nidrtPm, 
iip|"iininci',  122 
)«Titi.iiitis  in.  22."..     S.M.  Perituniih. 
jHTforativc  in,  Wl.  08 


644 


i.\ni:.\. 


Typl.    i,l  iVvnr,  poritvphliti-   „„J,  .litlVrc,,. 
tiiitiori,  4(i,s 
!"Tily|iliIiii-  ill.  •_':;,; 
l''Vi-  -  liiU.lir-  HI,  ',):;,  KH 
|>lmr\  11-  ill,  :;iMi 
pli'-Miii-.-iin  in.  ii/j 
pliN'l.ili-  in.   In;,   li;;» 
|ilil<':;riiii.-iii  „il,n  i],,],.,,,^  i,,     |,;., 
|ilili';;rii..ii-  in.    I.'KI 

liiii-unirl,i„,i,|  i„    |„,.i.„„,,,,„,  ,,,,,„.,ir. 
Ill I  i:i  ' ' 

I'l"unsy.  ilitli'iviitial  ,liii:;ii,,-i,    4|H 

pliMiri-v  in,    I  IT.  L'.'iT 

|'ni-iini..nia.  .litV.Tcniiiil  ,|i:,^r, „,,.;,   4|,^ 

>i  !■  uImi  l'iini)>n,nia. 
pn.  inn,, til,, nix  in,  SyX 
p'-t-iii.,i-l.Mn  c-.,n(liti,,n-.  m; 
pri'i;niinry  ami,  rcliiti,,n  ,,|-.   p.i; 
pr'v,-nti\r  iiiiTuliiti,,n  in    i;') 
|>r,ri;n,.-i,.  :>:> 

iiiliiiiiiiiiuriii  in,  :;ii4 
(■iniil;it,„.v  .,r-iin-  :in,|,  :;im) 
i''in.-titiiti,',ii  „n,|,  :;,s7 
lii'iilili  1111(1.  ;is7 
inli~tiin,|  ln-iij..ir|i]i.r|.  ;„    ;j,i,'; 
int. -tin,-  ;,i„l.  ;;:iL'  ""        ' 
kiilni\  in.  :;'.il 
Inn:;-:  in.  ■.\\i\     :;;i:; 
iii'plirili-  111.  :;:■( 
'"■i-np;iii,,n   Mini,  .i.si; 
p'Til'^iiili-  1111,1.  ;::,■_' 
pirllli-y    ill.    ;;'.i.| 
pniiini,.nia  in.  ;;;i,i 
^''■^  mill.  :;,s.". 
'•■'li-il  p,,-iii,,ii  .,11, 1.  ;j,i<,i 
ti-nip,Tiitiii'M  and.  .■;!)0 
pn,|,)nliirtir.  ,,f  liiitv.  47 
IiV"pli.\hi\iv  iii,livi,!,|.,l.  4.'!4 

ni.ii-iiivs  I,,,-.  4:i| 
pr,.ir:i,  |,.,1.  •_".«) 
p,-uli..^,--  in.  -ji;.-, 
piilni,,iiury  irunirnwic  in.  1'.",.-) 
inlanli,.!!  in,  L'.',.', 
tiili.riii!,,.i,  anil.  i,(',.  Us 
pill-  in.  HI.   l.vj,     .s,.,.  „i„    /-„/,„ 
piil-i-t.iiipi.nitiii-.'  ,,!'.  l;;i; 
pyiii-iii  in,  1!(| 


pM'  in.  niTV,,ii!,  sy.^tiiii 


ri'miili'-ci'iiii'  in. 


■iir-c.  H'i,  ;!44,  .350, 


n-lap.,.  with,  ;!i;;l 

t''rniiiiiiti..ii-.  ;;,",(; 
ri-(  rii,|cM-,.n|.  i".i| 
r.'il  c.irpiiM-l..^  in.   170 
rclfi'\r>  in.  •>~u,  :.'k:! 
r^'lap^.■  in,  :!44 

nlinrtivc,  .'i")9 

iit'rlirili',  .-{.'■i!) 

»'S>-  :iinI,  .iilO 

.nil-,,  :',(;■, 

<  lianiitiT  of,  A't' 

■  ,.iii-.(..  :!.-,(; 

iliamio-i^  and,  410 

'liira'.i.,ii,  .'!,-,7,  \\r,H 

l'n'.|iicnry  nf,  :i.-,!i 

inti-titmi  .-vriint.irii.s,  .35,5 

iii'Ttiilitv.  i?.',7 


'rypli.,i.|   1.  .iT.  niap.. 
ill.  .'I.'iii 
pn.i;no>B..  :{k« 
piilsf  in.  .■!.",!' 
iv,rii(l..vi!i.,.  Willi,  I!,;,-) 
ri'pcatiil,   .■;•,:! 

n>pinit..ry  artV,.|i,.ii-  in,  a56 
ri..»c.,|ii.  in,  :j.-,;i 
■-'■\  ami,  ."lid 
i-plci'ii  in.  .{41;,  ■;;,4 
ti'iii|MTiiliir..  in.  :!4i;,  .S4y 
t'Tiniiiati.iiis,  :!.",i; 
tinii-of,  ;i4.''. 
rcliip.-c,  in.  Hti.  471 

rrliip-in-  (-..viT.  ilirtVr..|,tinl  diau'm.H- 

4  I  * 
ri'p<iiliil  iitliirk-.  (17 
r,-piiii|,,n   ■Ti.'any  in,  L'ljH 

pi'-t-niiirniii  ,ip,„.„,-,,,„.,.    ]i:i 
n-Iiniil  lirni,,rrliiii;i>  in.  JS7 
rli.iiiiialic  pi,l\artlinii.s  with    ;j27 
ri'-i'"lii  in,  al,.-i-ni'c  ,,l',  1^',-, 
"T.  I'll ,1,(1  (V.iiii.   1^17 
lifi'  I.I',  iL'.'i 
lypliii.-  i-nipii,,n  iind    127 

■■" '•'■'■iiltiuv.-,  iiiil   in  dia^rnosi..    4i;:> 

ri'M'i.hi-,,f,  Ki,  IL'I 
rotlirlji  -.vith,  :!■_'!' 
^aliviiry   ::l:.nd..,  p..M-ni,,rt..,ii    ,1, „|.. 

s.aiM  f,-v,M' 1,11,1,  ,liiV,.,v„tiatii,n,  4l.j 

-riul.  t    I,. NIT   H  iih.   ;i;_>| 

■-'■iaticu  ill.  -^S-J, 
fidiTo-i-  in,    L'7i| 

" '"'■■">    r^pliili^.    .1  ll'iTcnlial    diiii'- 

n.,-i,.  41h 

I'cpticciiiia  and,  dittVrcnliiitinn    41:i 

.''■p'l'V'I'i"     ill.  '■'■n■l.^,^plnal    inonlii- 
iritis  with.  27o 

Sijiliri'lnir.   .'!l'.". 
si'ViTi',  2W 

of  atypical    ,.,„;,„.  „,„|    .vniptoinn- 

tiil.iiry      :!1  1  ■  ' 

>i'"iii.'i'  ciinilini.iis  in,  4,'',l 

i-lii'i'l  'n.iliiriiaiit,  L's.vi 

Ml  k-hi'd  in.  444 

sirk-r,,i,iii  di-inrrctinii  in,  437 

i-kin  in.  K\,   PJ4.  4(;<( 

.•■li'i-pini,..^  in.  L'dO 

.-iiiall-pi,\  and.  C").  ■.\2'Z 

ditli'n'iitiiiti.in,  41  r, 
soil  in  .■ti,,l,,;.r\  ,,f,  ,-,) 
spinal  ,  .,i-d  in',  278 

pi'-t-iii,,rt<'iii  app..aranco,  121 
■'liM'fii  ill.  171I 

pii>t-iii.,rlriii  appearance,   107 

puiirtiiie  1. 1',   (22 
-p'.riidir  ,11-,....   71; 
>tiiiiiii,  h  ill,  2(14 

pii>t-iii.,rleni  appeaninre,  HI 
•-ti")'.~.  di-inlee|i,,,i  ,,f  4:;,r-, 
stiHd*  in,  214.      S,.e  nh.i..SA,„/.,. 
.-iihMillii.,  ii.iiHiniiiii  in,  2tW 
siidaiiiina  in,  ;i(l| 
■«yiiiptMiiiiii,,|,,irv,  79 

variati,,!!^  in.  2«7 


i.\in:x. 


645 


I 


T.\i>liipiii  li'ViT,  iVTiipi. .ni>,  H;i.   \'22 
ill  iriciiliiiliipii  piTiiKl.  ho 
t«'iii|)cmlnn',  iiMiMitoi'    137,  Hj 

(li'M-.-iit  oi;   l:JH 

liii;li.   114 

(liiriiii;  .LiiMili'Mfiit'i'.  86 

iiiiiltijili'  .  l-\!iti'>ii>,   140 

pwiiliarilii-  ..!'.   144 

v.iii,iti..h-  ill.   I:l7 
teiii|iiTuiiin'-rin-vc,  umitiI  uf.   ]4'2 

ill  IlliM  rii-i-.,    1  17 

ill  .-tUlir  lit'   (IrliTM-.  .■111!',    14',< 

ti'iiiliiii-jcrkiiii;  in,  L'l.:; 
t.t.-iiiu--liki'  I'.iiHlitiMii  I  ,.  •.'(i4 
tliinl  Icliriji'  |MTi.iil.   I;i7 
tlii'iiiiil..isis  ill,   li;7 
tli,vi.iiil  -laiiil  ill.   18;i 
tli,vriii(liii<  111,   1h4 
t'liiLriii'  ill,  I'.i'.i 

;    -l-iihirti'iM  ii|i|>i'iiriiiii't'.  IK) 
ti>ii-il-  in.  L'lll 
tii\ir  ill  li. Ill  nil  iinnoii,  -v-tcni  in.  20^, 

-,v!ii|i|oMi-.  :!(i:{ 
tnirhiM  ill,  \H'i 

l"'-t-iii'ii-l ii|i|ir!(niiiio.   1 14 

•ri'iitiiiciii,  .■iiiti|ivn'tii'  iiirtlmd^  in,  4->'J, 
4i;i) 

liiilli-.  4-">.'; 

li,vili-..tli,i-i(|n  ,    !.-,( 

iiili-liii:il  ■•iiiii-cii-i-  in.  441 

siTiiiii.  4  HI 

spi'citli-.  4411 
tn-iimr  in.  I'd:! 
trii'lii.iM-i-  unil.  iliiV.  ri'iitinl  iliiii'ii.iai>. 

IIS 

Irisimi-  in.  ■_"14 

luli.TrllJ.isi,  Mini.   ililll'lTlitiiiniHi     41(1 

l,viilHHnn(l    ilitl'i'n-iiti.ui.in.  4l.i.  lilMI 

ii'liilinii  I,i1wm..ii.  oi'il 

"■' I:i'  in    .'i'.!!! 

iilii  r-  .if  inti-liii.i  in.  '.ii;,  :i.8  J 

iiivii  ill,   IS.",  I 

ii'ii-  :iriil  in.   ISr, 
iiriiiiiry  njipimilii-  in.   1S4 

"i\'iin«  in.  |Mi-t-iiioitiMii  iippeiininoc. 
11(1 
iii-ini'  ill.  S4 
ili-"liiliiillri.-i  in.    |H!I 
iirlic-iiriii  ill.   IL'H 

uti'Miii'  iimciiu^  iiiiMiilimiir  111,  I'.h; 
viiM'iiliir  .•ivstPiii   ill,   piKl-inortcni    up. 

pi  .iiiiico,  104  I 

vciii.s  ill,  I'il) 
viiinitin!;  in.  L'04 
wiilrr-ii|,p|y  in,    (:',•_' 
Wiilal  n:irti,iii  in,  i!;i 

Wifll.illt   illtr.-tilllll   !.'..iin|i-.    .".ii,    w 

Willi, lilt  ivph.iiil  -toiiU,  •Jli; 
Tvplinjcl  -pin,-,  -Jso 

-til.. Is.  L'U 

t'liiii-.  syiiipl -  ,|u,.  til,  .30.'! 

■|'\  pli.iiiliil  -tilt...  -JCO 
i'\  pli..i.ii.tti-.  L".i:i 
'r,vpli..iimliiriiil  fcvrr,  .320 
'r.vpliii-  iili.irlivii-.  2!IS 

!lt,'l\iilH.    ,'|,',4 


'l',\pliii~  .■uu.\..-ud_\  imiiiicus,  u.',4 
liiitli-  in,  (j3> 

llllTiTliln.   .'iSS 

mliirrlmli-,  :,:,:, 

llv-i'llLTll  U.-     ,').')4 

t  xuiitli'iii.  .VJ7 
Typliii-  I'l'MT,  47') 

iil.iirliv  ,u.-i>.  .Vi8 

iiliiiii..ii.iii  iiiij.  rclmiiiii  tiotwi'on,  .jii4 

iiinl.iilatitrv  ca^i'.-.  .V;! 

unll.ia\  ami.  liilliToiitial  <liaf;noi.ir.,  (iOo 

aiilip,'  !■.  ti.-  nnilhuJs  of  trtutiii-;nt,  Ul',» 

n'lii.cJic.  (,JI 
IiI'j'kI  rliaiii;i'>  in,  o\i'> 
(■U(la\  CIS  <if,  'iO*.! 

•  ■111'". if  arlidc-  ii-,.l  In   palicnU,  dim 
len-lirii.pinal  iiii-iiiiii:iti-  and,  dilliTni- 

tial  diaixiiiisi-,  ,V,iM 
oliaiiL'i'"  in  liliMid-M>.i,|.  m.  .'iliO 

in  rirriilat'irv  Mri;aii>.  .JJIi 

in  diu'i-tivr  trart.  •■|4" 

in  LriMiiiM-iirinaiy  nn;u'i>.  .j48 

ill  inari,   .'iL'."! 

in  ni-rMMi-  -y-li-m.   ",;!4 

ill  piil-f.  .'iL'M 

in  n-pinitiiT'v  orijiin-.   •■)42 

ill  -kill.  i;J, 
chn.iiir    iirtiTiiiiii-     .iiid.    ndation    lie- 

1  »'  nil.    .'1114 

''"'I'li'i f  "ii.'aii-  diiriiii;  con  ,  iilos- 

n-llri',   .■)7(l 
I'l'ii-tiliiiiiiii.  I'rt'iTt  ..f.  ,",i;.'i 

.■iill'al. -.■.■; Hl'7 

(•iiiniil.-ri'iit-.  di-rliar^'M  nf,  i;|() 
''"'"' •'  lariiilinn-  in  iiiaiiif.-iation- 

"I'll.  .-,.-,1 
•  i-.vpl.i^'.Miic     -.•piiropy.-iiiia    and,  dif- 

f'  I'l'lirial  iliiii;nii-i-.   .■|!i7 
dia-n.i-i-.  .Vi4 

ill  -!iii;i'  'if  rlilptl.iii.   .'illS 
dia^'ii.-lii.    vi^r,|i|i|.,,| ,■    pruptiiin 

.",!IS  ' 

dii't.  I'lji; 

iliHi'i-riil   Inini'    of,  ti'uipiTaiiiii>  vHrin- 

lion-  in.  .-,|H 
di^r.-tiv,-  ur^'aii-.  i;l'7 
di-iiif.Tii,,n  of  lii'd-liiini,  t;08 

of  fiirni<liinir,,  COM 

of  outer  rlotliinL'.  <!08 

of  -irk-rooiii-.  co'i 

"f  wards,  (',00 
dl-lriliiition,  180 
duration,  ,-,(;!i 

■  'lldrlllic--.   4!'7 

•  pid.'inii'.,  4!i7 
fr\-ipi.la-  ill.  .',:i:l 

I'.xaiitlic'inala  and.  ditfcri'iitiai  diairiin- 
-i-.  (K):', 
ndation  tictwcMi.  .'iCl.' 
fatal  cases.  ■,7,"i 
!;cn('ral  coiidilioM<.  4!i;i 
U'laiidiTs    .-.nd,    dirt'iTciiiial    diaenosis, 

i;o:!  " 

lii-tory.  47-"i 
liydrotlicrapv.  tlUl 
hyiriciiic  conditions  in  prophylaxis.  i;o4 


liiti 


/.\/>/,.v. 


iS5--«; 


Txptms  f.'vcr,  iiiiiiiuiiit\ ,  4h!t 
ii'  iliiMliooiJ,  .'ii;: 
iiH  iilmlii.ii  -tat;.'.  :Ak) 
i-c'luli.ri  ill  |.r..|.lnla.\i>.  iKM',  I 

lvrii|p|i-i;lariii  c  liaiii;i-.  .)L'i; 
tiiiilarial  ('•■v.-r  ami,' (Jillrnntial  iliai;!!,.. 

.'•i>.  ."i;i7 
iiiai.ili>tHli..ii-,  variation-  in.  .V.I 

t...  4;i7  '         ^ 

iiiil.l  la-i-,  ."..■>.'. 
in.>rl.iil  aiiat..riiv,  ftO" 
ni..rtalit_\ ,  .'i;.),  ':,Ho 

ai;.'  in.  .>.". 

I'Xlirnal  iiinditicii.-  in,  iJHo 

;,'<'.i!;ra|.liii'  (li>lril.iiti,,n  in,  &85 

in..i|.-  ..I'  lilV.  ox- 

cici Mi|iati..n  in,  .j^7 

piM--  .ual  .■.inditi..n.-  in,  uHo 

tiin.'  i.f  M'ar  in,  6>H."i 

wiath.T  ui,  ."iS") 
iii.T\..ii-  -_\  rnpLini^,  tj24 

>.\-l.in,"  r.ij 
n.iina  in,  .'.:::. 
luir-in;;.  (il:! 

I.e.  ii|ia,i..n  prpdisp..sin!:  t<>,  40ti 
"III  a;;.',  .■tl.'ct  ,,|',  ,-,i;i; 


ly|itm.-  I'l'HT,  >;    |.(.|.  I'lian;;.'.-  in,  OiJi; 
MiMi'pliliilii\,  4MH 
?«ralini.',  .jL'I 
>_\  iJipti.Tn-,  .'il.i 
U-n.p.ratur.'  iji.  ,")|;i 

II:  I'.^innliiL:  >Uii;c.<,  ,".14 

III  lal.r  >tat;i'.-,  i')14 
tran^nii...-i,„.  ,,r,  |,v  ,|,.,„i  |„„ji^,j    ^^^ 

"■'"i-r'Tt"!! 'f  liali.'nt,    lUMi 

Ircatiii.'nl,  l.atli,-,  (13) 

liMlri.lli.Tapi,  (il',1 

I'l'  i.ruani.-  <lianf;i'.-,  022 

"I'  spivial  c'l.nditi.Mis,  ti^li 

np.ii-air,  i;i"i 

.-p.'.ili,'.  i;il! 
t.vj.li..i.l  and.  ditC.Tcntiati.in.  4IS 

ri. la-  in,  .'■,!i!i 

vaiii.lji  and.  diH'iTcnlial  diairiLisis,  6115 
vc'ntilat'..n  in  tn-alincnl,  flir. 
wnsliini.'  (.!'  li.ifj.ital  i!.. thing,  C07 
le\i-.irnus,  -JtlS 
ncrvi.Mis,  .■..■>4 
sidiTan.-,   ".Hd 


I'liKA  in  typliiii.l,   1H& 
l]ri.'  a.'id  i'n  typli.iid,   \Hr, 
rrinan  hji|iai-alii-  in  lyplinid,  184 
.ii-L'aii-  111   .•.■nMil.'.-i.'nci'   IV.. Ill    tvphdid 

;i7x  • ' 


I'p'ii-aii-  tn'atiii.nt.  til.'i 
pen. ..I  ,.f  (..innloccnic,  'if.!! 

..i;,l..tVrv..-,-,.,i,.,.,  fnip,.mtu|vin,Mr,  i,,    t.vpli..i.i,    p..-t-n„.rt.  ni  apiH'arance 

..(  ,i;n-al.>t  danircn.t   Hil\cti..n,  4Hi;  no  i  iitaiani-e, 

pn('iin,..nia  and.  .lim-rcntlai  diagn..,.-!.-,     Iii,,.     |,„,.i||,|,  n,,l„„,i-  i,,,  :',2.  34 

» ii.ilii\ .  :;'t 
.|i-ii.li-.-li..n  ,,r.  in  t\|,||.,id.  4.i6 
ill  t\plii.id.   ll-J,  184 
ri-..l.ilinuria  ii    tvplici.l,  18!i 
rrtii'iiria  in  l\pli,.id,   128 
I  tiriiH'    niiiiM.ii.,    iiH.iiil.mn..    in     tvphnid 
li»;  ■  ' 


r,(p:! 
pr.iL'ii.'-i-,  ■)7'>.  ".K.'. 

a;;.'  in,  58'i 

disj'Stivi'  (iruiin-  in,  501 

I'st.Tnal  ('..ndili..!!.-  in,  aSS 

cv.'  in.  "lOl 

Ki'n.Tiil  syiiipt..ni?.  .18!! 

h.'ni..rr.iin,'ic'  plivnoniona.  f)!t2 

inilividual  ..r.;ans  in,  o8!» 

iiiPtiM.ri*iii  in.  ."i!t'2 

miKJp  lit'  life,  in,  AST 
"f  "ii-i't  in,  58!l 

nfTVi.ii-  sy-tciii  in,  .VtO 

•loriipati'.n  in,  'i>*7 

p<'r-..nal  I'.mditii.n^  in.  .')8.5 

respirat.iry  iin;an.-i  in.  .'i!ll 

spvi'rity  of  syinptonis  in.  .589 

s'rciii  in,  r)!)2 

tinip  ..!'  y..ar  in.  fiS') 

w.'iitli.  r  in.  .'iH.'i 
pr. .)  liyla\i>.  i;04 
rpiiirrcnci^  in,  rifil 
rrlap-.-  ill,  .''i.'il 


rclap-inixlVvpran.l.ditfprential.Jiau'n.)-    Wi.lal  r..|i,ti..'ii,  L'!),  4 


Variola,    t\pli..id     anil,    dirt'.rpntiation, 
41.-.  ' 

typliii^  an. I.  dirtcrpiitial  diaj;iio.-i<    ',<)(, 
\      with  typli.ii.l.  322 

'Vascular  -y^tciii   m  typhoid,  i«itl-iiii,rtpm 
app.-iiriiiii-...  i((4 
A  . '11. .11,-  tlir.iiiil....i- in  coiivalescpiu'e  from 

typh..i.l,  .■!74 
\'.'r-.atil.'  niTM.u>  I'.-vpr,  312 
\'.>niitini;  in  typhoid.  204 

Wai  KR.  hiKillii-  typli..piis  in,  vitality,  ISO 

.li-infpcti. f,  i'l  t\ph..id.  4.'i7 

rolp  of.  ill  typh..id,'40 

W.ll-watpr,  typlioi.l  fpvcr  from.  41.  4,'?    . 


.MO 

rp>^pinitory  ..mans  in,  620 
roseola  in'  iVM 
scarliitina   and,  ditfi'i-.'ntial  diajriiosis 

spasoii,  4il7 
spx  in,  4!HI 

ptfiTt  ..f.  r.oo 
skin  clianir.'s  in.  .V27 
xx'iul  c.inditioii.s  in,  4% 


.■arlii'-t  ap)ipaniii( f.  427 

ill  typhoid,  423 
niacr..sco|ii|.  nicthi.d  in,  420 
niiriiisci.pir  in.'thod  in,  420 

..(•(Mirr.'ni f.    limp    plaii-inn    l.pfopp 

42!i 
!.ro;,'n..stic  siirnilicaiipc  ,.f,  430 
r.  Inli..ii  of  -.-riini  and  ciiltiiri-  in.  428 
spiTilicity  of,  42" 
Widals  method  of  ai,'j,'lutinatii.n,  425 


*f -'^/^—i 


*■ 


'*;!f 


££?U^ 


•■¥> 


r-.JSt^.' 


^^^.■v>Pi^,?;-^^P^i 


Catalogue  SL  Medical  Publications 
W.  B.  SAUNDERS  Cf  COMPANY 


PHILADELPHIA       ».  *  *  *  w 

925  Walnut  Street        w  »  *  W  * 


LONDON.  W.  C. 
161  Strand 


Arranged  Alphabetically  and  Classified  under  Subjects 

See      page      20     for      a      Lilt      of      ContenU      clasiified      according     to     lubiecti 


111  lif  uli- 

it»licatif)n 
nt    li.)i>ks 


Tiil.  \n,..l-.  idwrtiseil  in  this  CataloRui-  .l^  1.  iri'j  u'/J  ty  iuhcri;/i,v  arr  usually 
iiiU'.l  Iri.ni  tr.ivfilini;  s,.lii  iiors.  hut  iluv  will  In-  s«-nt  ilin,  i  Iruni  th.-  ..fliri-..t  pi 
(ih  iri;.  s  of  sluiuu.-ut   pp-paiil)  up'in    ini-ipl   of  \h>'  prlc.-,   i;iv.'n.     All   llu    .,it 
.i.lv.ru^.'.l  .111-  inuini..ulv  for  s  il.'  Iiv  lioi.ksi-ll.rs  m  .ill  put-  ..I  tl.r   rnilnl   St.ili-. ,  li 
will  I"'  ■.i-iit  -..1  .my  aililn-ss.  (.iiriiRi'  prt-puil.  on  n-cnpi  ut  tin-  piihli-!ii-il  price. 

M.uun  nmv  In-  si-nt  .at  the  risk  of  tin   pulili-lur  in  eiilii-r  ol  the  lollowinK  w.ivs 
iiiMii. A  ..nlrr,  an  expre--  inoniA  oriler.  u  ti.mk  i-hick.  ami  m  .1  reKistm-d  lettir.     Miiii.  v   ~,  iit 
■M    :nv  o'li.-r  M  n    i~    It  ll"  n-k  ol   the  senilcr, 

SPECIAL      To  pli\si,  1  ins  .,1  .ippriiveil  iredil  1 k-  will  l..>  -  tit,  p..-t-p,,iil.  on  ih.    foil,, wing 

OFFER      terms    S5.n0  i.  ish  upon  ililiviTv  of  books,  .iiul  ni,,nlliK  p.nnu-rit-  o'  #5  01,  there- 
after uiit  I  lull  amount  is  paid.     .\ny  one  or  two  volumes  will  be  sent  on  thirty  days   time  to 

ilioM'  w!i.,  ,lo  not  caie  t,»  in, ike  .1  lirf;e  [lurch.ise. 


I 


An  American  Text-Book  of  Applied  Therapeutics. 

i'.tiiud  liv  I\Mi--  (  Wii-'iN,  M.  I>.,  I'lolcsor  ot  I'iMiliif  ol'  Mt'diiine 
and  of  (liniial  Moiln  liic,  IflTfrson  .M(.'(li(:il  ( 'o11cl;o.  l'hila(ti-l],liia. 
Haiiil-omi'  iniporial  01  la\i)  \oliiiii('  of  1  ^d  iiaf.jc--.  llliistrati'd.  (loth, 
S7.00  net  :   Slu'cp  or  Half  .Morotio,  5.S.00  net.      S,'/./  Av  S:i/>si'ri/'fu'n. 

An  American  Text-Book  qf  the  Diseases  of  Children. 

Secor^d  Edition,  Revised. 

Kditfd  liy  l.oi'i'-  Si akk,  M.  I>.,  ConMiltint,'  IVdiatrist  to  the  .Vlaternitj' 
Hos|iital,  etc  ;  assi^tL•d  liv  rMii\iP~ii\  S.  \\  i>iiin  1,  M.  D  ,  .Xllending 
Phy>ii  ian  to  the  1  )is]icns;iry  for  Diseases,  of  Children,  Hos|)ital  of  the 
University  of  l'enns\  Kama.  Haniisoine  inii)erial  odavo  vohinie  of 
1244  paf^es,  jirot'iiselv  ilhistrated.  Cloth,  i?7.oo  net;  Sheeji  or  Half 
Moroei  o,  f.S.oo  net.      Si>/,/  /'x  Su/'Sc-rip/i(>>i. 

An  American  Text-Book  qf  Diseases  qf  the  Eye.  Ear, 
Nose.  Gild  Throat. 

Edited  liy  (1.  I".  UK  Sihwiimi/,  M  D.,  I'rotessor  of  CJ[)htha!nioloi,'y, 
lefferson  Medual  Colleoe,  Philadelphia;  and  1'..  Ai  i-XANriKk  K.anhai.i,, 
NI.  1).,  Clinical  I'loiessor  of  Diseases  of  the  Far.  University  of  Penn- 
sylvania, imperial  01  laso  of  i-isi  jiaoes;  76f)  illustr.itions,  59  of  them 
in  (olors.  Cloth,  S700  net  ;  Slieeji  orii;,lf  .\Ioro(  i  o.  s;8.oo  net.  SoiJ 
by  Subsinf'ltoii. 


^  fur 


\..-4 

mm 


h'^ 


I  ^ 


Ml  I^ICI!     I'l  HI  n    \  I l,)\s 

An  American  Text- Book  qf  Genito- Urinary  aiid  Skin 
Diseases. 

'■'l'"''.i'^    I      l-M..-.    l;xN,...  \I    h.   |T„t,..,„r  ,„   (,■■„„„  I  rniarvSur 
i;m    lnuc-r.,u   ,umI    IviKnur   l|,,.|„,,|    \l,,|„,i  ,  ,,||,,,,     \,.„    ^^^^ 

M.un   \l,.,l,..,l      oll,-,:;c.      In,,,,,,,,!  ...  law,  w.lu.,,.- ol   ...,,  ,„„...    .,  „  ,   -  o. 
n.Km  m,,  an.l  .o  lull  puKc  .  oloro.l  |,l.Uc-v      ,  lo.h.  .S7.00  .u-t  ,   Mur,   o 
Halt   .M.,r<)..,).  .SS  00  lift.      A,-/,/ /r  .V;//.„v////,.//,  "iM"r 

An  American  Text-Book  cf  Gynecolojfy.  Medical  an<) 

dUr^lCal.       Second  Edition.   Revised. 

.llu>f.a,„M.  n,    ,h,.   „.v,,.n„l   .vS.ol.Mv.l   .,n,l    I,.,Im,mh.     ,latcs       Clo.h 

An  American  Text-Book  qf  Legal  Medicine  t/nS  Toxi- 
cology. 

r|,anu„,„        „1K,„.    „,     nn.,,,.,,.    ,„„l    N,„...,n..    .Vw    Nork      a^  d 

An  American  Text-Book  cf  Obstetrics. 

I.l.t.,l   U   K„n,K„,.   N,,„,.,   M    ,,       „,,    ,,,,„„^^   ^„„^^,    ,     ,,^^,^_ 
K-arlv  „oo   l„.a„m„i   ,  „1,.„..|  ,„„1   hal. „„„..   ,llns,ra„on,.      Clu  1,    ^.oo 

An  American  Text- Book  qf  Pathology. 

MolH'i'rdi'.'"';  /''''''''•  ,",  "•  ''^"'^■^^'^'  '"  '•'"'"i"^^-  '"  t<".h 

'"    •"">'^"vn    llN. ,,   ,n  ,lu-  I   ,mr,.,U   ,,1    IVnn.xhaina.      Ila.i,ko„K- 

^n,.,^.,l,„,a^o,o^,.,    ,.oo|M„..|„>,ns,.K    ,l|,M,a,.:,l.      A,  .SV,.^„ .v.^;^ 

An  American  Text-Book  cf  Physiology,     second  Edition 

Reviled,  in  Two  Volumei. 

K.laol   l,v   WuMu,    li     11, .wn.    l-„    I,.    Ml,,    ,-,oa,..or  of  I'hvs,- 
olo^N,    |oh„,   llo|,k,ns   1  nucMlv.    Ilai.unor,..    M,l        IV,,  nnal  o.tavo 

:    :nnc.o.   al...,    000    ,,a,..   ca,l.       l„li.    ,ll,M,a,..l.       l■c■■^olumc 
t  lolh.    svoo   nn  ;    >h,v|,  or   Half   Moio,  ,  „.   j;,5  75    ru-t. 

An  American  Text-Book  qf  Surgery.    Third  Edition. 

.'litc.l  f,v  UiiiMM  U.   Km  s,  M.  1).  i  I     1...  ,     k    ,-.s.:Hon   r  and 

'^""^^'"'"-•^'  "-I'-l*.  ll-..NonK.  o,,a^o^olunK•of•,.o 
M,o-s  .  .,',';  "oo,!  ,  ut,  and  ,-,7  ,  olorrd  and  half  ton^  plaKs.  Thorou-^hv 
revise.!  and  cnlar,..d,  w„h  a  ...  „on  .l,.o„-d  ,0  ■■  The  Use  of  the  ko,',^ 


Bi..l.- 


()!■   If  n    \i/  \/>/a:s 


CO 


THE  NEW  STANDARD 


THE  NEW  STANDARD 


The  American  Illustrated  Medical  Dictionary. 

Second  Edition.  RevUed. 

lot  I'l.ii  liUuiu  !>.  ami  M.iiliiUs.  A  (oiiiplL'ti-  DniioJiary  of  xhx  If  mis 
iiM(l  III  Midii  inc,  Surj;rry,  1  )i'nti^try,  I'haniiai  y,  C  hiMiii>lry.  and  ihe 
kiiuln-il  liniii.  liL-^,  iiii  liidiii^;  iiiiK  h  <  ollalfral  mtoriuatioii  ot  an  fn(  v(  lo- 
[Kilh  <  harai  tcr,  loj^cthcr  with  luw  anil  ilal'Dratc  lalilcs  ol  Arteries, 
Muv  le>,  N\r\c-i,  Vein-',  etc.  ;  ot"  IkH  illi,  llai  ttria,  Miiroioiii.  Stri'|ilo- 
(O'li;  l^poMMiiK  lalik-sof  I  )iM'aM-s,  (  Jpcratioiis,  Si^'ns  ami  Svniiitoiii-i, 
St;im^.  ^L•^l^,  Melliod-  of  Irratmciit,  ..-ti.,  cli  .  Hy  U  \  Niuman 
Di.ki  Wh,  A.M.,  M  1>,  l.ditor  of  the  "  .XiiK-ru  an  i'o  Uel  Medi.al 
|)i(lionar\  "  llamiM)iiie  Ku^;e  oita\o,  tieailv  Soo  |>a^es,  hoiiml  in 
full   iIcmIjIc  leather.      I'ri.  e,  i.».so  net,    with   lliuinb   iiulev,  fS  oo  net. 

Give*  a  Maximum  Amount  of   Matter   in    a    Minimum    Space    and   at   the  Lowest 

Pouible  Coit. 
Thit  Edition  contains  all  the  Latest  Words. 

"I  muii  ,u  kriiwl'-.l.-'-  mv  a-ii)ni-hmi-nt  at  srcing  hew  mip  h  lir  ti.is  cnnilrn";!-!!  with;r 
rrlaiivclv  Mil, lit  >\>Mc.  i  iind  n.jlliiMi;  to  tntici-,?.  vrry  n.uih  tu  .  ommrnil,  .mil  w.i^  intrusted 
in  fiii.llni;  50mc.it  ilie  nf  .v  minis  wliuli  .ire  nut  in  other  reifnt  iliitionarirs.'  —  Ri'sWKl.l.  I'ARK, 
/V  Aj.,.ri./  /'//*;,  i/,V/  j'lJ  /'r.uti.t  ./  Sur^'ery  .in  J  (.'inu.iiSurffty.  Cnivrr^ilv  ,/  Huff  ill,: 

■■  I  ,  onRralulati-  voii  uji^n  iiivins;  to  the  prok-SMim  a  (liclion.ity  >o>oini>Kt  in  11*  structure, 
nnil  Ml  r.-pl<-t.-  "ith  inform  iiioii  r.-.|miea  by  th.-  Lusv  iir.iclitionet  anJ  stiidrni  It  1.  ,1  nec.-^Mty 
as  «'-ll  as  in  inf.irm.-.i  lompunon  M  .'Vitv  dortor  Ii  -lioul.!  lu-  upon  thr  desk  ol  ev.-rv  pr.u- 
titioner  an.l  sluaent  ol  m.Mi. me  -lulls  H  Mtklllv.  I'r.Juwr  cj  ^urgtry  jn.i  C.i'r.il 
Sur^'f'v     .'.'orlkwtitifft    i  ftiverufv  MiJudt    .^A.'j/,  Cluc.igo. 

Third  Edition, 
Revised. 


The  American  Pocket  Medical  Dictionary. 


Kilited  liv  W.  .\.  Niw\i\N  I>iiKi  wn.  M.  1>.,  .\s.sl>tant  Ohstetru  lan  to 
the  ll.)>iiital  of  the  I  ■niver>ilv  of  IVnn^ylvania  :  lellow  of  the  .\nier- 
ii.in  .\iadeniv  of  Meilii  inc.  Containinf.;  the  |iroinin(  lation  and  delini- 
tion  of  the  |irinilii.il  words  used  in  inedn  ine  and  kindred  --i  leni  es,  with 
64  extensive  tables,  llamKoiiielv  liound  in  llexilile  leather,  with  uold 
ed"es.      I'rii  e   Si. 00  net;   with  thunili   index.  :^i.25   net. 


The  American  Year-Book  qf  Medicine  ant  Surgery. 

.\  \earl\  1  »i,L;e^t  ol  Srieiuilir  Pro^ies-s  and  .\iithorit,iti\e  Opinion  in  .ill 
liram  hes  of  Medii  ine  and  Surj;ery.  drawn  from  journals,  monographs, 
and  le\t  hooks  of  the  leading  .\nioriran  and  Foreign  authors  and  in\esti- 
},'alor^.  .Xrranued  with  iritiial  e>iitorial  (Oinments,  hv  eminent  .\nier- 
iian  spei  lalistsi  under  the  etlitorial  <  har^;e  of  CiHiRr.,.;  M.  Coiit).  M.  D. 
Yearl'.ook  of  1901  in  two  volumes  -  Vol.  I.  imludin};  (iLtinitt  MfJuine; 
Vol.  II.,  Gnieiiil  S/i'xrrv.  IVr\ohinie;  Cloth.  .<,voo  net;  Half  .\Io- 
ro<io,  .<,V7,s   net.      S,>/,/  /■v  Suhuriplion. 

Abbott  on  Transmissible  Diseases,    second  Edition,  Re/Ued. 

The  Hy^^iene  of  'rransmisFihle  Diseases:  their  faiisalion.  Modes  of 
l)i.s,seniination.  and  Methods  of  Prevention.  Hy  A.  C.  .Akhoit.  M.  I»., 
Profes.sor  of  Hvfriene  and  Haeteriology.  I'niverbity  of  I'ennsylvania. 
Octavo.  351    i)ages,  with  numerous  illustrations.     Cloth,  ^2.50  net. 


V  .  ••  » 

r  -^  •       K   •- 


,.-X. 


•■  >  *; 


m. 


"rJA-;'  ::i*- 


« -»  i;.  ..,,4.-  ^iij 


■  ■■'/>■.  1 , 


MICROCOPY    RESOLUTION    TEST    CHART 

ANSI  ond  ISO  TEST  CHART  No    2 


1.0 


I.I 


*"  iilllM 

!:  1^ 
It  i^ 


m 

II  2.2 
I  2.0 

1.8 


1.25 


1.4     llli  1.6 


^     ^PPUED  irvMBE     Inc 


-■j':tiesler.     Je*    'or*.         1*609 
'16)   *82  -  OJOO  -  Phone 

ne)  2S8-  '-989  -rQ« 


-^^ii^l^M^^^S^'^^tiy^^'^^ 


^%">./:' r*c 


'■*■•■ 


i^l^t'^V 


3'  i 


4  Mi:i)/CA/.   rriu./cATioxs 

Anders'  Practice  c'  Medicine.       r^  ^~^~„ 

\     |pt  i''H;k    o,    ,1,.    lY:„„rc   of   Medicine.      Hv    Iam.  >    M     ,\m„.rs 

>imi,al    .\I,(||.  iiir,    Medu  o-t  hiniri;u  a     Colli-.r     l'hili,l,-li,hi.,        ii       V 
M.n..  o,  ,av,.  .oh,„K.  of  ,.,.  ,,,.^ MW  Hlu^t^;^       C  o  .  s'  n"!': 

Mieej..)!  ll.ill    Muro,  ,,j,  ^0.50  net.  ^ '"ui,  .ss.  ^o  net  , 

Bastin's  Botany. 
Beck  on  Fractures. 

S,5.5o  net  "  '^ '■'   '■^'•^'■^'  '  7°  ilIu>trat,ons.      Cloth, 


Beck's  Surgical  Asepsis. 


A  ^^anllal  ot  Suri^i.al  .\sei,-,i>.      IIvCmi    Hi,  w    ^tI>     < 

Mar^-s  Ho.,„a,  and  „..  ^...  ^■,„,  ,.nnan',;:i;knn,     l^"^;::  ",:!; 

'',  text-,ll„strat,on.and  ■  •  lMll-|,a,,e  platev      (loth,  s...^  nei 

Boislinie^e^'s^  Obs^tetric   Accidents.   Emergencies,  an? 

(olle-'e.      ,,s,   |,a,,.s,ha„dM,n,ely  ,lln>trate.l.      (  loth.  ,..00  net. 

Bohm.  Davidoff.  and  Huber's  Histology. 

«■    <M<i    llr',,,.   \       ,  „     -     ^'^    "^v„„„r.   of   Munieh.  and 

o'   -.5  I.a,es.  .,th  ,3.  l,ean,.,„,  ..^.^d  n'usUanons.  'rlo;;:':;;.;:  ^ 

Butler's  Materia  Medica.  Therapeutics,  and  Pharma- 

COIOgy.       Third  Edition.  Revised. 

Hv  <;:",':';1    nl  ,'!T'|>;,  ?■-'-•  ^'--l—-   --l    I'hannaeologv. 

.-o.  S5^;o  lief'  ""■"'■      '■'°"-  ^*°°  "^■'  ^   ^h-1'  -  "^'i'-  Mo: 

Cerna  on  the  Newer  Remedies,    second  Edi«on.  R.vi.ed. 

^^:so;..i,,^;:-,rt^w;^,;\:;,:---^^ 

""en  an.l'l'r':;!'''^^  ^'^I'-'    ne.ant.enrnm'e,!,:,;  '^r    :i^'"'^ 
r.t.u,  and  „.atlv  enla,,..,!.     I'ost-o,  .a^.;,  .5.5  payes.     rioth,  St.oo  ,k'. 


OF    li:    /.'.  S!C'.V/)/-A'S   J-    CO. 


Chapin  on  Insanity. 

A  Conipcndnini  of  Iiisnnily.  l!y  Jmix  li,  (iiai'in,  M.I).,  I.I.I)., 
l'hysi(i;in-in-C'hic/,  I'cmisvlvaiiia  Hospital  for  tlic  Insane  ;  Honorary 
Menilicr  of  tiic  Mcdiro-l'sycholo^ii  al  Soi  icty  of  (ircat  li'jtain.  of  the 
Soi  iuty  of  Montal  Modu  inc  ot  ISclgiuni,  cti  .  Tjnio.  254  pages,  illus- 
tratL'd.      (loth.  Si. 25    I'ct. 

Chapman's   Medical    Jurisprudence  and  Toxicolo^. 

Second  Edition,  Revised. 

Mcdi(  al  |uris|)rudeni  c  and  Toxic  ologv.  Hy  Hk.nkv  C.  Ciim'Man, 
M.  !>.,  rrofcs>or  of  Invtitutes  of  Medicine  and  M(  diial  Jurisprndem  e, 
Jefferson  Mediral  College  of  I'hil.  deljihia.  254  pages,  with  55  illus- 
trations and  ;  lull  pa^o  plates  in  1  olors.      Cloth,  Si. 30  net. 

Church  and  Peterson's  Nervous  end  Mental  Diseases. 

Third  Edition,  Revised  and  Enlarged. 

Nervous  and  Mental  Diseases.  l!y  Aklhiiim  n  CiiiKrii,  M,  D.,  Pro- 
fessor of  Xer\ous  and  Mintal  I  )iseases,  and  Head  of  the  Neurological 
Department,  Northwestern  Cniversity  .Medical  School,  Chicago:  and 
FKi.i)i:KKK  rnrKKscix,  .\I.  D,,  Chief  of  Clinic,  Nervous  Department. 
College  of  Physicians  and  Surgeons,  New  ^'ork.  Handsome  octavo 
volume  of  875  pages,  profusely  illu.strated.  Cloth,  #5.00  net  ;  Sheep  or 
Half  .Morocco.  S6.00  net 

Clarkson's  Histology. 

A  'le-st-ilook  of  llistolog\.  Descriptive  and  Practical.  P)V  .\KrnfR 
('l,.\KKsc)N,  .M.  li.,  C.  .M.  i;din..  for.nerly  Demonstrator  of  Phvsiolo^'y 
in  the  Owen's  College,  .Manchester;  late  Demonstratoi  of  i'h\>iology 
ii\  \orkshire  College,  Leeds.  Larj^e  ocia\o,  534  jiaues  :  22  engravings 
and  174  lieautilully  colored  ori-mal  illustrations.      Cloth,  S4.00  net. 

Corwin's  Physical  Diagnosis.    Third  Edition.  Revised. 

l^sseniials  of  l'h\>ical  Dia.L;nosis  ot'  the  Thorax.  l!y  .XuriiiR  M. 
Coinvix,  .\.  M.,  .M.  D.,  Instructor  in  I'hvsical  Diagnosis  in  Rush 
Medical   ( 'ollege,  Chic  ago.     2icj   jjage^.  illustrated,      (loth.  Si. 2s   net. 

Crookshank's  Bacteriology.     Fourth  Edition,  Revised. 

A  Text-liook  of  liac  teriology.  Ily  KhCAK  M.  Ckoc )K>ii.\\k,  M.  H., 
Professor  of  Comparative  I'athologv  and  Hacteriologv.  King's  College. 
l.ondoTi.  ( )c  tavo,  700  i)ages,  2-7,  engravings  and  22  original  colored 
jilatcN.      Cloth,  Sd.sO  net;    Half   Morocco.  S7.50  net. 

DaCosta'S    Surgery.       Third  Edition,  Revised. 

Modern  Siir^erv,  ( ieneral  and  Operative.  l!v  |..hn  Chvimik-  D.\ 
(-iisi.v,  M.  I).,  Professor  of  Princ  i|)les  of  Surgerv  and  Clinical  Sur>:erv, 
Jefferson  Medical  College,  i'hiladelphia  :  Surgeon  to  the  Philadelphia 
Hospital,  etc.  Handsome  octavo  volume  of  1117  pages,  profusely 
illustrated.      Cloth.    S5.00   net:    Shc^ep  or   Half  Moroc  o,   $f^  00   net. 

Enlarged  by  over  200  Pages,  with  more  than   100  New  Illustrations. 


-.  .  V 


Mi-iuc.  I  /   /'/  ■/,■/,  /t  •  /  r/oxs 


t\ 


Davis's  Obstetric  Nursing. 


<>l-ictn,     and    (ivMu.ol,,^,,.    Ni.rsmj,^.      liv    Ki-waki.    I-     Du-.s     AM 

.ici,.h,aS;os,,u''  .a,  r^ :;;,!"';'''''  ''>■"-"'"«-'."  "^^  •'""- 

DeSchweinitz  on  Diseases  of  the  Eye    tk  ^  r^ 

*!^    '"t^   M^yc.     Third  Edition,  Reviled. 

Dorlanus  Dictionaries. 

[See  ■/""■'-- /^'_>/-A-/.,^.,^V„/  P/,-,.,.,.,,  ,,„,  .,,,,,, ,,,^ 
/   '</!v/  Afr./i,-,!/  Du-ti.'ihiry  oil  |>;ij,.e   5,  ] 

Dorland's    Obstetrics.       Second  Edition.  Revised  and  Great..  Enlarged 

M.Mlrn,   Oh.tcivKs.      Ily   W.    A.    NiuM^N    1.,,,,,  ,m,     m    ,,       ,     • 
<;vne.olo.v.    I'h,)a,lcl    h        IM       ,    ,:        ;;' / -"'-|^'"'^' :   Asso.  ,a,e   i„ 

Eichhorsfs  Practice  cf  Medic 


ine. 


AText  lUiokofthr  I'ra,  ti.  c  of  Me,ii,  iiie     Ih  I  )k    Hiix.vvr, 

Friedrich  on?  Curtis  on  the  Nose.  Throat,  fl«2  Ear 
Frothingham's  Guide  for  the  Bacteriologist. 

Lalioiatorv  Ciiide   lor  the  Da.  teriolo'  isi        li,    i   w    ,     .     f 

Garrigues*  Diseases  of  Women     tk  a  ^..  ■ 

,,  ,  ^      »»wilicn.       Third  Edition.  RevUed. 

.'i>ca.scs  of  Uo.nen.      I!v   [iiN.v    [    .;vkk„,,,s     A    ^^      m    ,,     ,. 


or    IV.   li.  SAUXDERS 


CO. 


Gould  and  Pyle's  Curiosities  ^   Medicine. 

Anomalies  and  CunohitiL's  of  Medicine,  liy  (iKiiki;K  M.  Gi»li  w,  M.  ]).. 
and  Waiikr  L.  1'vi.k.  M.  I  >.  An  one  y<  lopedir  <  ollei  tion  of  rare  and 
extraordinary  ( ascs  and  of  the  most  striking  in^tanc  ts  of  ahnonnality  in 
all  brani  hcs  of  Medicine  and  Siirj;ery,  derived  from  an  exhaustive 
resean  li  of  meiiical  literature  from  it>  orij;in  to  the  jiresent  day, 
abstracted,  dassified,  annotated,  and  indexed.  Handsome  c«  tavo 
vohnne  of  oti'^s  l^gcs  .  i()^  en},'ra\  mgs  and  \2  .iill|iaj,'e  |)kues.  I'ojdiiar 
l';dition.      Cloth,  S.5.00  "'■'t  '■   ^1  eep  or  Half  .Morocco,  >4  00  net. 

Grafstrom's  Mechano-Therapy. 

.\  Text-I'.ook  (jf  .Mei  hano-  I  licra]i\  1  .\lassa;;e  and  Medical  (lymnastics). 
Hv  .\XK1,  \'.  (;KAK>rKi)\i,  I!  Si  ,  .\1.  I).,  late  House  I'hysician.  t'ity  \\<x>- 
jiital,  I'lackwell's  Island,  New  \'ork.  unio.  \y)  pages,  illustrated. 
Cloth,  j;i.oo  net. 

Griffith    on    Ibe    Baby.       second  Edition.  RevUed. 

The  Care  of  the  Hahy.  I'.c  J.  1'.  Ci<i>/lk  (Iklllim,  M.  1).,  Clinical 
Professor  of  Diseases  of  Children.  Cniversity  of  i'ennsylvania  ;  Phy- 
sician to  the  Children's  Hosiiital,  Philadelphia,  etc.  i^mo,  404  pages; 
67  illustrations  and  5  jilates.      Cloth,  $1.50  net. 

Griffith's  We'-ght  Chart. 

Infant's  Weight  Chart.  |)e>igned  by  J.  P.  Crd/f.R  (Iriffith,  M.  D., 
Clinical  Prot'es-.or  of  I  li^eases  of  Children,  L'ni\  trsity  of  Pennsyhania. 
25   (harts  m   each   pad.      I'er  pad.   50  t  ts.   net. 

Hart'!^  Diet  in  Sickness  arib  in  Health. 

Diet  in  Sickne>s  and  Health.  P.y  Mk>.  Kkni.-i  Hakt,  formerly  Student 
of  the  I'acultv  of  Meiiicine  of  Paris  and  of  the  London  School  of  Medi- 


(  ine  for  Women  ; 
F.  K.C.  S.,  M.  I). 


with    an    Intro(hiction   by   Sik    Hl.NkV    Thcimi'm)N, 
.ondon,      :^::o  pages.      Cloth,  51.50   "et. 


Haynes'  Anatomy. 

.V  Manual  of  Anatomv.  P.y  Irvinc;  S.  Hav.n-f.s.  M.  D.,  Professor  of 
Practical  Anatomy  m  Cornell  I'niversity  Medical  College.  6.S0  jiagcs  ; 
42  diagrams  and  154  fuU-jiage  half-tone  illustrations  from  original  jihoto- 
graphs  of  the  author's  dissec  tions.     Cloth,  j;;.5o  net. 

Heisler's    Embryology.        second  Edition.  Revised. 

A  re\t-P.ook  of  I'.mbrvology.  P.v  John-  C.  Hri-irk.  M.  D.,  Professor 
of  .Xnatomv,  Medico-Chirurgical  College,  Phibdeljihia.  Octavo  volum.e 
of  405  pages,  handsomely  illustrated.     Cloth.  S^J-.sO  net. 

Hirst's    Obstetrics.       TWrd  Edition,  Reviled  and  Enlarged. 

.\.  lext-licjok  of  Obstetiu.--.  liy  I'.nkion  Ct'Oki.  }1ik-i.  -M.  1>.,  Professor 
of  ( )bstetrics,  rni\ersitv  of  Pennsylvania.  Handsome  octavo  voliinie 
of  S75  pages  ;  704  illustrations,  ,^6  of  them  in  (  olors.  Cloth,  <:5.oo  net ; 
Sheep' or  Half  Morocco,  50.00  net. 


y': 


9»E 


I 


A'^/V: 


"!iS^ 


t 


•'//•■  nn  AL    J'CJU./C.l  IIOXS 


Hyde  -"^  Montgomery  on   Syphilis  ant  the  Venereal 

LTISeaseS.       second  E*tion.  Revised  «^d  Greatly  Enlarged 

pro.usdv   liluMnucd.      Cloth,  .4  cio  nl'i;^    '  "'"'    -=^'^-*   l«8^-^' 

Ihe  International  Text-Book  of  Surgery     ,  . 

■  ai  s,  „„„,.  „„.,„„ ,  ,„„  V  ','.;":„■,';;::;:■;;'■ ,°  TTk  ;'-°r,"  ■■"""- 

"11     l'r;i(ti(al    Siirt:vr\    and     Iri,  hrr    of   ,     "  ••  V'  *^- *-  ■  •^■.  I-«-'ttiiriT 

HaiuUiiu-   ,„Ku„.   ,M-    ,,a„,..    with      "^   /  "'•    '.■/-""■^v/  .S//y-,-.i  ._ 
l.tho«ra|,hH    nlatr.  ol     T  V  '    /  -^-^•'   ''^'"""•"'    '"u-stfations  aiuj   9 

Sheep  or   HaIfMo,o::rroo  Ik'.':'^  ''"  ^"'"""•'    ^•'°"^-  -^5.00   L-t; 

01  o|,..r.u,ons  h.ci.lly  ,l™Til,.-,l  ,„  .,II  nvL-^^T   "\\Jj      »     f"'  /'^'"^''''---'ly  i-  tin-  tecliniq,,,- 
a  very  remarkahk-  .l..i;r.v.  „,anv  „f  -I,,.    ,n..,  •■^"''  '*'"'^''  ''"■  "">l-  '^  nn  1.,  ,1 ,,,.  |,, 

body  I,dn>,  «,ven  in  7„li  d.-.lulV  S    Ue       n"  -^  H?'''^  '"  ""i  '''"■■■"•'"  "''^--l    urn  of  ,  ,1 

Jackson's  Diseases  cf  M^  Eye 

College  tor  .;rX"s  r  M.:,,,:"'  ■■:;  '''"!-'■ ''''^1^' ''»'-'-"  -^<i 

Keating  s  Life  Insurance. 

As.o,,at,on   o.^   \k\^'^^''''T'^'     '^''    '   'H- :  •  Al'.v.ident  of  the 

Keen  on  /A.  Surgery  cf   Typhoid  Fever. 

opcrat,o.>.s.  J;         .^^"'  '  '"'''"''•-Ir''""-      iViec  per  pad,  l.latiks  for^lf^ 


OF    If.    /!.  S.lf   V/)/:A'S   Ct-    CO. 


Lockwood's  Practice  qf  Medicine. 


Kyle  on  the  Nose  and  Throat,    second  Edition. 

I)ist■a.^t■s  of  Uio  NoM_- ami  1  hroal.  lU  I ).  I'.kmhn  K\  i,i  .  M  !»..  Clmicil 
I'lorosor  of  l^ir>  iiL'olo;;)-  and  Rhiiiology,  jcllVr^on  Midiral  ('dIIit^c. 
i'hihi<lrliihia.  ()ita\(),  (^d  Jiaj^t-,  ;  omt  150  illustration^  and  6  liliio- 
j^raiihic  plates,      (.'loth,  #4.00  ntt  ;   Slit.'c|)  or  Half  .\1oixh:(  o,  is5.oo  net, 

Laine's  Temperature  Chart. 

Icnipcraturc  (hart.  Prepared  hy  I).  I'.  I, mm,  M.j).  Si/-  Hxi^Ji 
inches.  .\  lonveniently  arranged  Chart  tor  re(or<linf,'  ■l'enii)erntiire, 
with  (ohinnis  for  <laily  amounts  of  I'rinary  an<l  i'e(al  lAcrctions,  lood, 

Remarks,  etc  .  On  the  liac  k  (jf  ea(  h  chart  is  j,'i\en  the  iSrand  treatment 
of  'I'vphoid  1  ever.      I'rii  e,  p(.T  |<id  of  25  iharts,  50  (  ts.  net. 

Levy,  Klemperer,  and  Eshner's  Clinical  Bacteriolo^. 

The  l^lement.s  of  Cliniial  liacteriolo},'v.  i!\  Dk.  l-'.kN^r  I.iny,  I'ro- 
fes,sor  in  the  I'niversity  of  Straslimi;,  and  liii\  Kii'MiTRrk.  I'ri\at- 
docent  in  the  Tniversity  of  Straslnirj;.  'rraiislated  and  edited  by 
Alcasirs  .\,  Iv~iim  r,  .M.  IV,  I'rotessor  of  (■|ini(.d  Medicine,  Philadel- 
phia Polyclinic.     (t(ta\o,  440  paj^es,  tully  illustrated.     Cloth,  $2.^0  net. 

Second  Edition, 
Revised  and  Enlarged. 

.\  Manual  of  the  I'rac  tii  e  of  Medi<  inc.  I'.v  ( ii  <  ii;i.i  Roi.  {.(iikwcMih, 
M.  1).,  i'rcjfessor  of  j'rac  tn  e  in  the  Woman's  .Mediial  College  of  the 
New   \'ork    Infinnarv,  etc. 

Long's  Syllabus  cf  Gynecology. 

.•\  Svllalius  of  ( lynec  olo-^'V,  arranged  in  Cont'ormitv  "ith  ".\n  .\merican 
'I'ext  Hook  of  (Ivnei  oloLiy.''  l'>\  J.  W  .  I.i'm;.  M.  |).,  Professor  of  |)is- 
ea.ses  of  Women  and  Children,  \ledi<al  Colle,i.'e  of  X'ir^inia,  etc.  Cloth, 
interleaved,  S'-oo  net. 

Macdonald's  Surgical  Diagnosis  anZ  Treatment. 

Surgical  I>iai;nosis  ami  Treatment.  I!y  J.  W.  M.-xchon  \i  i>,  M,  D, 
l-ldin.,  !•'.  K.  C.  S.  lidin.,  Piofessor  of  Practice  of  Surgery  and  Clinical 
Surgery,  Haniline  University.  Handsome  Oi  tavo.  800  pages,  t'ully  illus- 
trated.    Cloth,  Js.oo  net;  Sheep  or  Half  Morocco,  J6.00  net. 

Mallory  and  Wright's  Pathological  Technique. 

Second  Edition,  Revised. 

I'athologiial  'i'echni.iue.  .\  I'nictital  Manual  tor  lalioratorv  Work  in 
Pathology,  iiacleriologv,  and  Morbid  .\natom\.  uith  ihapteis  on  i'ost- 
Morteni  'i'echni  [iie  and  the  IVrformam  e  of  .Autopsies.  l!y  I'k.snk  H. 
Mm.hiky,  A.m.,  M.I),  .\ssistant  Professor  of  Pathology,  Harvard 
Cniversity  Meilii  ,il  School,  Uoston  ;  and  I.\mks  11.  WKicm,  .\.  M., 
.M.  |i..  Instructor  m  i'athology.  Harvard  Liiivcrsity  Medical  School, 
Poston. 

McFarland's  Pathogenic  Bacteria.  ""tlEfo'TJi/So'^aS/" 

'i'c-\t  Honk  u]ion  the  Pathogenic  i!acteria.  Bv  jcisKi-ii  Mc  }•  aui  \m>, 
M.  1).,  Professor  of  Pathology  and  I5acteriology,  iMedico-Chirurgical 
College  of  Phnadeli)hia,  etc.  Octavo  volume  of  621  [lages.  futely  illus- 
trated.    Cloth,  S3. 25  net. 


10 


A///>/(. :  1 1.    /'I  •/,■/  ic,  t  T/OA'S 


..J 

It 

i'} 


Mei^s  on  Feeding  in  Infancy. 

I'tviJniL;  III    l'.arlv   Iniaii.  v.      I!v    \k  mik   V     \ri,,,       vf    i .       i. 

Moore's  Orthopedic  Surgery. 

A   Manual   ol    (),t!.„pr,li,    Sur.vrv.      l!v  [am,,   |.;    m,„,^,,    ^,    ,,     ,.   _ 

Morten's  Nurses'  Dictionary. 

'.-"""'"^   "'    ^'•■''"■'1    I'""-  an,l   XniMi,^  'I  ivattncnt.     Con- 


.\iir^i.'-> 
taiiim 


Nancrede's  Anatomy  on^  Dissection.    Fourth  Edition. 

Ks-t-miaUor  Analonu  an,|   Manual  of  I'ra.  ti.al  I  )is,o  t 


Ni  ki  I'l  .   M.  I»..   1,1,.  II..   !• 

iivr\.  lni\rrsiiv,)t"  .Michigan.  .\iin  .\rl,or 


on.    H\Ch\i;iis 

ulc^Mir  ut  ,Su,-o,.rv  and  of  Clinical  Sur- 

V)si 01  ia\o.  500  iinj^fs.  with 

a 


(  K.th  .  or  <  ),i,  loih  for  .l,..o  „on  ro,,,,,  ,,  ,s..oo  net         "  "''"""^-     '■'"" 

Nancrede's  Principles  qf  Surgery. 

I.otMv^ontlu.  l'r„„,|.k.,  of  .-^.rurrx.     \'.^(uy..\)    Nan,  kki.f    M    I) 

Norris's  Syllabus  ef  Obstetrics,    thw  ca«™.  r„,^ 

intrrk-a\ccl  tor  note-,.  S2.00  net,  T'lJ-'-S-      tioth. 

Ogden  on  the  Urine. 

nini.al    l-.vnn, nation  of  the  Trino  an.l  Trinarv  Diagnosis       \  Clini,.,! 

Cli.nVhool         1         ,''''•     '■  "••   ''""■"""'    '"   <i'™>-strv.  Harvard 
.MCdicai    >(  hool,       lland-onu-   oiiaxo      1  1  r.   i,-i.,-t    „iti,  ii  • 

and  a   nnnil.r  of  .olored  plates.      (KHh!  ^  !  o^^""   ^^   '"--'»- 

Penrose's  Diseases  of  Women,    rourth  Edition.  RevUed. 

A    ie.xt-l!ook  ot    Diseases  of  Wonicn.      l;vCinku-,I;    Ppv,.,,.    \i  r> 
r,t      >     torinerlv   iVotessor  of  (ivnecolo^v   in   the   l';,'!;:,  ^   r  Pe      1 
«3  r's  net.        '^""  ^""""^^  "•  538  pages,  hattdsoniely  tlh.strated.     t  loth, 


OF  ii:  /;.  .s./r.\vv;.v.s  or-  co. 


XI 


Pryor— Pelvic  Inflammations. 

I  he  'Crcattiiciit  ol  l'(l\i<  lnllaiiiiii;ilions  through  the  \'a>^iiia  IJy  W 
R.  }'kvcir,  M.1».,  I'rolcsx.r  of  ( ;y;i.-(  ology,  New  York  rolyclinic! 
rjiMo,  J4S  pagts,  ha^ll^olllLly  illustraicil.     Cloth,  $2.00  lu-i. 

Pye's  Bandaging. 

I-'.lL-inciitaiy  liaiida-in-  ami  Surj;i<al  Dussin),'.  With  Dirc(  linns  con- 
(crninj,'  the  Iiiiiiiediate  I  rratiiKiil  of  (.'ases  of  Kiiicr{,'cni  y.  ('.\  Waitkr 
I'yK,  K.  R.  C.  S.,  late  Sur-ton  to  St.  NJarvN  Hospital,  r.ondoii.  Small 
I  21110,  over  So  iihistratioii-.      Cloth,  llexihie  <  overs,  75  ets.  net. 

Pyle's  Personal  Hygiene. 

A  Manual  ot"  I'ersonal  llygiLiie.  I'nMrr  Living;  tijion  a  rhvsiolo^'ic 
l'.;isis.  JMited  hy  Wamh;  I,.  I'vi.t,  .\l.  I).,  Assistant  Siirj,'eon  to  tlie 
Wills  Hye  Hospital,  I'hiladelpuia.  Oc  ta\o  volume  01'  344  ]>a-es,  fully 
illustrated.      Cloth,  .nt  .50   net. 

Raymond's  Physiology.    Revi.eH^"^S creMj^E^lurged. 

.\  Text  I  look  of  l'hysiolu,-\.  l;\-  jo-i  ni  H.  Kwm.im,.  A.  M  ,  M.j).. 
Professor  of  i'hysiolo.Ljy  and  Hv,L;iene  and  i.edurer  on  Cvnec  oioi:y  in 
the  i.onj;  Island  Collei,'e  Hospital. 

Salinger  and  Kalteyer's  Modern  Medicine. 

Modern  Medicine.  i!y  |ri  11  s  I,.  S\iin(;ik,  M.I).,  Demonstrator  of 
Clinical  Medicine,  Jefferson  Medii  al  CoUeLre  :  and  V.  ].  Kaitfvfh, 
M.  I).,  .\ssistant  Demonstrator  of  Cliniial  Medicine,  Jefferson  Medical 
CoUe-e.      HancUome  octa\o,  Sot  ]iaj,'es,  illustrated.      Cloth,  S4.00  net. 

Saundby's  Renal  and  Urinary  Diseases. 

Lectures  on  Renal  and  Crinary  Diseases.  ]W  RniiiKr  S.\fNnn\',  M.  D. 
I';din.,  {•'ellc/.v  of  the  Ro\al  College  of  I'hysic  ians.  London,  and  of  the 
Roval  .Medico-Chirurgic  al  Society;  I'rofesscr  of  Medicine  in  NLison 
l'olle,L;e,  l!irniiiij;ham,  etc.  ( )c  ta- o.  434  pages,  with  numerous  illustra- 
tions and  4  colored  plates.      Cloth,  ^^.50  net. 

Saunders'  Medical  Hand-Atlases. 

See  p&ge>  16  and   17. 

Saunders'  Pocket  Medical  Formulary,  sua  Edition.  RevUed. 

I'.y  Wii.i.iAM  M.  I'owiM.,  M.  1).,  author  of  "  i.ssentials  of  Diseases  of 
Children";  Member  of  I'hiladelphia  I'athologiial  Society.  Contain- 
in;,'  iS,(4  formuhe  from  the  best-known  authoritie.^  AVith  an  Appendix 
(ontainiiig  I'osological  Table,  I-'oriinil,e  and  Doses  for  Hyi)odermie 
Medic  ation.  I'oisons  and  their  Antidotes,  Diameters  of  the  I'emale  Pelvis 
and  Fetal  Head,  Obstetrical  I'able,  Diet  List  for  A'arious  Diseases,  Mate- 
rials and  Drugs  used  in  Antiseptic  Surgery,  'I'reatmcnt  of  Asphv.xia  from 
Drowning,  Surgical  Renieinliranc  er.  Tables  of  Inc  oinpiatil.les,  I'.ruptive 
Fevers,  etc..  etc.  Handsomely  bound  in  tle.xible  morocco,  with  side 
index,  wallet,  and  flap.      52.00  net. 

Saunders'  Question- Compends. 

See  ptge  IS- 


13 


'//■ /)/(•..//.   f'Ci;/  /CA  I loxs 


Scudder's  Fractures,     second  Edi«„„.  RevUed. 

Ii'-    I  rc.iiiiiuni   ,i|    It.i.  lures. 


111  ( 
IliK  k 


\o    ^«„    ,,    '■'"";    ^'"^K'O-  'l-'rvaM  I  MUffMlv  M.di.al   S,  h.iol 


Senn's  Genito-Urinary  Tubercul 


OSIS. 


Senn's  Practical  Surgery. 

(•"llr...  (■hi,,„o,      H,n,l      n      ,:  <  l'"„  al  .s„r,...ry.  Rush  Medical 

Senn's  Syllabus  qf  Surgery. 

\    Svllal.iis   III    I  .■■  i]i,,.,    ,,,,    ,1,      1,  .  ^ 

""""•^    ^^^"'  ••  \n        ,..     ,    'V';:",:"  L  "'.^"^^'^'"■■••^^^nnKcd  in  ,on- 

-''■-ai.;,i..v,,..,,i.,,':;'r::;;;":;';^,::-- 

Senn's  Tumors,     second  cm...  Revved 


o  net. 


ui.i,    .->-..,,._    .""■"  "  "ll^-'.l  hi.ai;...      ( )M;u  ()v„ln„u.ol    7  i,S  ,, a,- 


"       '"""" "In   111.  IiiiIiiil;    t-    full  1,1..,.  ,,I,i,.     ,„  i  —  v'h^ 

>5.oo  net  ;   Sl„v,,  „r  Half  .Moio,,,..  iu  '  '  "'"'^       '  ''^" 


.00    llcl 


Starr's  Diets  for  Infants  and  Children. 


<l'Hdren.''    /^o  I      nk.    ,,„,  V  , "      ?' •'''    '^■^'  ''""^  of  the  I  Hsenxs  of 


Stengel  «/,?  White  on  the  Blood. 

^ylvania;     n,!  c.  y.  U,„m     L  '     ,^'''<l" '"e    I  ^,^e^Mtv  of   IVnn- 

l  iiivers.iy  of  IVnn.vlNnnia;      /V/v  I','  '"""""^"'  '"  •'''"''''I  ^'^'-li'  'ne, 


.ilions.      Rv   .AiiRKn 


-^-^ 


I 


or  II    /{.  s.hc:\/>/:a'.s  ^-  co  ,^ 

Stevens'  Therapeutics.    Third  Edwon.  r^u^j  .„d  G«Miy  Enlarged. 

A    lf\'  r..i.iki)f  MimI.tii  I  licr:i|.i'iiiii  ^.     \',\    \     \    ^n^iv.,^  \    \|     \|    |, 
l.otur.T  ,.i,  l'livM(al  Di.i-iiOM^  in  the  CimcrMtN  cl    l'<iihs\  Iv.iiim. 

Stevens'  Practice  qf  Medicine,    rifth  Edition,  RevUed. 

\  M.iiiii.il  ot  ilu-  I'raclitc  of  MrtlK  in,,-.  l',y  A.  A.  Sikvkns,  A.M., 
M  I'.  I  ci  mill  nil  l'h\^H.il  I  ii;i;;iio-is  111  the  I  iii\ci-  'V  of  iViui>,\l- 
\aiii;i.  >|n-i  i.illv  iiiiriiil.-d  I'ur  >!ii(1liiis  |iir|.ai iti^;  lor  LTadiiation  and 
ho^pltal  I'xaiiiiiiatioii^.  I'o-it  oi  taso,  5K;  pa^f^;  illii>U.i'' d.  Flc\ii)lc 
l.tMllicr,  .sj.oo   net. 

Stewart's  Physiology,     fc  urth  Edison.  Revi»ed. 

A  -M.inual  of  I'lu-^iolo-v ,  ^^lIl^  I'laiiical  l!\ri(i^(s,  lor  Students  and 
I'rai  titioncrs,  lly(i.  N.  Sik«\kr.  .\l.  .\.,  .\l.  |),  I )  Si  .  I'roft-^sor  of 
l'hysioloj;y  in  the  Western  Uimim  I  niv.  i,ii\ .  (  It  m  land,  <  )liio.  ()(  la\0 
volume  of  iS94  |iaj,'e-.  ;  ;,;,'<  lilusiraiion--  and  5  <  olored  plates.  Cloth, 
.<,)  75    '"-■'■ 

Stoney's  Materia  Medica  for  Nurses. 

Materia  Medici  tor  Nurses.  l;y  l.Min  .\.  M.  Shim\.  late  Su|ierintend- 
cnt  ul'  the 'rrainin^;  S(  hool  lor  .\iirse>.  Carney  Ilos|iital,  South  lioston. 
Mass.      Ilandsonic  octavo  volume  of  ?o()  jayes.      I'lotli,  .•;i.5o  net. 

Stoney's    Nursing.       second  Edition.  RevUed. 

I'rac  Ileal  Points  in  Nur^iii};.  For  Nurses  in  rri\ate  I'rac  ti(  e.  Itv  Kmii.Y 
A.  .M.  SioNiv,  late  Superintendent  of  the 'rrainiiii;  Si  hool  for  Nurses, 
(arnev  Hospital.  .South  lioston,  Mass.  456  pa^e-.  w  iih  7;,  enj;ra\iMgs 
and  S  (  olored  and  half  ti.-ne  plates.      Cloth,  >  1 .  75  net. 

Stoney's  Surgical  Technic  for  Nurses. 

Haiterioloi,'y  and  sur^^iral  Tcchnie  for  Nurses.  I'.v  i;\iii  v  .\  M,  Sh.m  v, 
late  Supermtcndeiit  of  the  Trainiiii;  s,  hool  lor  .Nur-es.  (  arnev  lli)^|.nal, 
South   llo-iou.  .Mass.     j  jino  \oliMne,  liill_\  illustrated.     (  lolli.  .>;i .  j^  net. 

Thomas's    Diet    Lists.       second  Edition.  Revised. 

|)iet  l.i.sts  and  Sn  k  Room  |)ietar\.  Ilv  |ii<(imi,  I!.  Thomas,  M.  D., 
Visiting  Fhysii  ian  to  the  Home  for  Frieiidleis  Women  and  Childieii 
and  to  the  NeHslio\s'  Home  ;  .\ssistant  \  isitiiiL;  I'hvsiiian  to  the  Kings 
County  Hospital.      Cloth.  Si.-'i  net.      .^end  f  r  sample  .-heet. 

Thornton's  Dose-Book  and  Prescription-Writing. 

Second  Edition.  Revised  and  Enlarged. 

Dose  I '.00 k  and  Manual  of  I'reM  ription  Writin-.  l;\  I',.  (,).  'rimuMdN, 
.M.  !).,  Demonstrator  of  ]'hera[.eulii  s,  Jeffersoii  Mediral  College,  i'hila- 
delphia. 

Van  Valzah  anS  Nisbet's  t>    ^a,.os  of  the  Stomach. 

Diseases  of  the  Siomarh.  i',y  ".'.liiiwi  W.  \'.\n- \' ai /ah.  M.  D.,  Pro- 
fessor of  Ceneial  .Medii  ine  and  1  liseases  of  th^  Dij,'esti\e  .System  and 
the  lilood.  New  \  ork  I'olvilinie;  and  J.  Dntci.AS  Nishkt,  .M.I)., 
.\djunrt  l'rofrs.sor  of  C.eneral  Medirine  and  Disea.ses  of  the  Difjestive 
System  and  the  lilood,  New  York  I'oUdinie.  Octavo  -.olume  of  674 
pages,  illustrateil.      Cloth,  ."^3.50  net. 


M 


i 


l'4  i 


t 


0.  1 


'%-/- 


■VI-DIC.tl.    JT/lI./C.ir/ONS. 


Vecki's  Sexual  Impotence. 


The    i'.itliolo^.y   anil     I  nalin, 


Second  Edition,  Revised. 


\-,,,.,    ,,    ,"•    , '  '"   •-'t-v'iai   im|ii)i.-ii,  ,v      l;v  Vi,  i,,k  r 

lv:.V:>L:^,::™;':T;;;;:.'-r;,;:;""" '•-'-"«^: 

"th  Edition.  Revised. 

I'l.  l'r,,t,sM,i  ,,|   Mfdi.  me, 


V,erordf5  Medical  Diagnosis.     rou.H  Edition.  Revised 

woo.,...;,.,,;;,,;  ^  ,,„     i;-'  ;",:;;;;•;"'"•■•<••  '-.^  i-k-;  .,, 

Mor,„  ,  „,  5,  ,..  ,„.(  '''"'•  ^■♦•°°  '"^'J  ^hcep  or  Half 

Watson's  Handbook  for  Nurses. 

\    llan,ll,„.,k    lur    N.,.  ,..       1;^   ,     k     W  ',^,.n     \\    |,    ,    ,;,         ,         . 
o..       .vs.al    |.,a,n.,,„.   I  „n,,,,„  „,   1  Vmmm  Ik,,',  .       ;  ^  „      i,    '"""" 

Warren's  Surgical  Pathology. 


^ii'Ki'al     I'alh.il.i 
M    l>.    I  I.   1 


Second  Edition. 

'-<■>.     -Ilon,^,     IVol.-,.,r    ..r    S,„..,v,     llarvar.i 


noioKv.  <,ou..,,.oo...;  Sheep  on;:i/'^;;,i^:-^^:i''^-^- 


SAUNDERS; 

ARRANGED  IN  QUESTION  AND  ANSWER  FORM. 

The  ..ost  Complete  .„a  Best  liWated  ^erie.  „,  Co.pend.  Ever  Issued. 

NOW    THE    STANDARD    AUTHORITIES    IN    MEDICAL    LITERATURE 


Students  and  Practitionerj  i 


I  every  City  of  the  United  State,  and  Canada. 


OVER  200.000  COPIES 

of  th,  .e    ..nrivalici    ,mhlic,u„,„s    l,nve    Leon   soM        Tl,l       .,  ,      ■ 

ev,.l.„cc  „f  „„  value  .f  ,he..  ..,f,,,,,,,  T-'v;,,,  ^^^  ^^''^Z.  "    """""""'" 

SEE  NEXT  PAGE  FOR  LIST. 


SAUNDERS' 
f        QUESTION-COMPEND  SERIES. 

t  Price.  Cloth.  11.00  not  pe,  copy,  except  when  otherwUe  noted. 


I.    Citentials  of  Phyiiology.     Hv  ;it>NTV  Ptnci  rr   \f  I )        I   V    ■  If    / 

^'  *^''"m'u°'^'?tt-,,,I;:;,:,;''''"  "  ^^-•<^'".  ^'  >•  >-.i.  h,„„„,  ,1,,.. 

4.  E..enti.l.  of  Medic.,  c^^^^^^                                ,„„,^.„i^  ,,  I.wk,  v,  k  V\,„  r^. 

'■  *^"''"m ',',"!  °!"*'""-      "^'^     '----VA s.  NM,      K.,„„h„| ,,„,„.„, 

6.  E.,entU).  of  PMhology  «nd  Morbid  Anatomy,     liv  K     I  Ku  ,m>r.  M    „      /, 

7.  E„entia,.„f  Materia  Medic..  Therapeutic.,  and  P^^  ,;,,„,., 

8.  9.    Eiiential.  of  Practice  of  Medicine.     I'v  IIknkv  M,,kki,   M   I,       .„  A,         i 

i.v   ;„o    F,Mni,il    K.rnn,!..     .1    ^    I    ."^ '  ■  ■^'    "      '  I""'  '■■iiti.....  cnl.irKcl 

i'..wM,, M ,.  :;;;:i.,!.';::;;:;';:ai';r;j7''' "" ■■•  -"^ -. h w«.^i 

10.    Ewential,  of  Gynecology.      l:v  I  i.u  is    1!.  ,  K^..|^    M    | ,       I-,„|,  ,,„  i 

■    'li!H,n.  icM-i  .|    nri'l    i_Ml.il  ■>  <| 

IS.    Eitenti.!,  of  Diieaie.  of  Children.    liv  \Vi,.,  ,am  M.  lou  m  i    MI,      ii,i     , 

.6.  Euentiai.  of  i^.„i„.«^  „,  „,„,.  „.  ,^„.^^^, ,  ^,:;;,  ,,  l'"" ;: ;- 

17.    Euentiali  of  OiagnoiU.     liv  s.   S(„,is-C,,iii  n    M  I)     i„  i   A      \     i- 

"•    ''""^,°!„,':'f:^j::,°^    '""™'---      "^-    "••■-    ^-    S.VKK      S..,„,    .„„on, 

20.    Essential,  of  B.cteriolo«y.     Hv  M.  V.IUi  i ,  M.  I,      F„„,,l,  ,■.!,„  n 

2X    EssentiaU^of    Medical    Physic,.      V.y  Kk,,,  J.    ...kwav,   M.I).     Sec.,.,,1  H.non, 

23.  E„ential.oiMedicM   Electricity,     .v  „.u„,   U.  S,kw.kx.  M.  „  ,  .„a  K...k„ 

24.  E.,ential,  of  pUease,  of  the  Ear.     liv   K.   li.   (;,fa.,,n     M  n      W      i      , 

^^■vl^,M   .111,1   i;,c:it:y  cninrj;t.'il.  '  ■•tA-'N,    M.  U.      .Second    edition, 

as.    E.,ential,  of  Histology.      Ily  T.,„.„  l.s.ov,  M.  D.     \Vi,h  yj  ung.n.i  illustration.. 
P.mphic,  containing  specimen  page.,  etc.,  «n,  free  upon  application 


4^^"^- 


■'M 


Saunders'  Medical^  Hand-Atlases. 

VOLUMES   NOW    READY. 

Atlas  and  Epitome  of  Internal  Medicine  and  Clinical 
ifiagnosis. 

..  .1.,  lio.~.oi    o.   (  „nu,,l    Mcii.nu..  I'hila.lrlplna    I'civ,  lini,-       Uith 

Atlas  of  Legal  Medicine. 

,';-,'"      '••.^•;"\,  "V'^'^^^.   "'■   Vienna.        K.litcl    In-   pRm-KirK 

M,  ,..,,,  c,„,l   Nn„.on,    Nc-u    ^  ,„k.      W  „h  ,  .o  '  olurc.l  ,  .., "'    on   ^6 
Pbtc.  and    ,„,   l„.a,„„„l    hall-lunc   illu..,aUons.      <1oth,  ../jo  nc"      ' 

Atlas  and  Epitome  of  Diseases  of  the  Larynx 

M.     »..  ]'hv.„,an  ,,,(  ha,:,,..  TInoa,  and    No,e  |)c,,ar,na.ni.  llo|,  Hlo^" 
'^'"\7'     ■    '"    '-""r^l^ania.     \Vnl,  ^.;,,,l,Hv|f,,M^•^son    .        1   ,. 


:i""    I.-  ;    |M,-cs   of   tr\t.      CI, 


>lh,  v-'.;o   nc-l. 


Atlas  and  Epitome  of  Operative  Surgery. 

|U(',",/m    f!'^:'^^^^'"-   ;"■    Vienna.         i:,l„„l    I,.    ).    (hmmiks 
-•,;  .eM-,]l,Mr,.„Mw,an,i   -„;  ,,a„.,of  u-.U      CI,,,!,.  ..  ,.oo  ne,       '  ' 

Atlas   a"jJ_^Epi^tome   of    Syphilis    and   the   Venereal 


!■>■     I'l;"l.      I'l:.      IkW,'      \||,\, 

lie 


IK.     of     \   il 


■nna.       I.iliicd    liv 


li:n:;:ne^^.L";jriu:i;:.:;\\;i;r-c'\:^^^^ 

elates,  ,.„hMnnion.,an,l,..    ,,a,e.  o,   u.,.      <  1o,l,.    •  '  3;',:;;'"'"' 

Atlas  and  Epitome  of  External  Diseases  of  the  Eve 

;vr::^r:;:;:;;-;;:;;!:-;^r-',- 

Cloth,   s,;.oo   11,1.  '  '    --'^   I'-'fe^''*   o'    '<-'-'^t- 

Atlas  and  Epitome  of  Skin  Diseases. 

liv  IVur.  I.K.  lKVN/Mnu,K,of  \i,nna.      Kdi.ci  l.v  1 1 ,  nrv  W.  Srrr- 


\V\.,nN,     M.    I).,     (ij,,,-,,,!     J.,o|-^.,,y, 


Atlas  and  Epitome  of  Special  Pathological  Histology 

■v   liK.   il     |)rK,K.  of  Muni,h.      K.iited  l.v  I,,i,ui,,    lliKimv   M    n* 
rro  cssor  ot  I  -atholo^v.  Rnsh  Modi,  al  folleue.  (  h,,  a.o      h  '  ruo    h  n 

16 


Saunders'  Medical  Hand-Atlases. 


VOLUMES   JUST   ISSUED. 

Atlas  and  Epitome  of  Diseases  Caused  by  Accidents. 

I!y  l)K.  I'.i..  (Mii  I  i;ii  -A,Ki,  of  licrlm.  'Ir;iii>latc(l  ami  cilitfd  with  addi- 
tions l,v  I'lxia  I.  Dviiiv,  M  I)  .  Attciidiii-  I'hysiriaii  to  the  I)c]iartiiiciit 
ot  (  oriLi  liori.>  and  lu  tin-  \iiii>noi^c  and  Iiuuraliic  Hospitals,  New 
\orl<.  Witl,  40  loioivd  plalc-^,  14J  trxt-ilhistrations,  atid  'loo'iia'cs 
ol   text.      Cluth,  >4.oo  net. 

Atlas  and  Epitome  of  Gynecolo^. 

liv  1)K.  ().  >H\i  i  II  1;.  ,,f  HeidelWcr-,  /■),-///  ///,■  S,:;.n./  A'rr/s,:/  Grr- 
ii:.iii  EJitioti.  IMitcd  l,y  Rl.n\ki.  C.  Nmrkis,  A.m.,  M.  I).,  (Jyne- 
folo-ist  to  the  Metiiodist  KpiMopal  and  the  Philadelphia  Hospitals- 
Miri,'eon-in-Charuc  of  Preston  Retreat.  Philadelphia.  With  90  colored 
jilates,  (.5   text  illu>tration-,  and   ,5o.S   pa-es  ol'  text.     Cloth,  >,5.5o  net. 

Atlas   and  Epitome  of  the  Nervous  System  and  its 
Diseases. 

By  Pk.1I  I -.M,i;  |)k.  (.-iiK.  IvKoi:,  of  laian.-en.  //vw  ///,■  S.coihl  Rc- 
viiiJ  dnJ  i:<]!.i>-,,/  Criium  F.Jilioii.  r.ihtod  hy  Khw  ak:.  I).  lisiiiK, 
M.  I).,  Prolessor  of  1  h-eases  ol'  tlie  Nervoi:-  >\-Uiii.  Liineisity  and 
Pellevue  Hospilai  .Medi.  al  (  olle-e,  New  \ork.  '  Willi  8  5  plates 'and  a 
(  opsous  text.      (  luth,  s,;.5o  net. 

Atlas  and  Epitome  of  Labor  and  Operative  Obstetrics. 

l''.^'    I 'I-    < '.    S.  liMiiiK.    ,,i-   lleideliei-.       /-/.v//   tii,     /■:/.;:    R.iisr.i  aii.i 

/■.ii,',,j.:,j  (;,,i,i,Ni    A,///.v/,.      Indited   l.v   1.   Ci  II  ic>\  i:iM,\i:.   M   1) 
ProlesM.r    ol'    ()b-,telri,  ,    and    Cliniral     Mid'uiierv,    (  oniell     Piii\eisily 
.Mcdi.al  .-^rhool.      With    !,'(,   .oidied   illustrations,      (/lotii.  S-Voo   net. 

Atlas    and     Epitome    of     Obstetric     Diagnosis    and 
Treatment. 

Py  I  »K.  (  I.  .s,  II  \i  iKKR,  ,)!'  I  leiilellier-.  /-iv,,,  ///,  .V, ,,-//,/  /,'  is.J  .ni./ /ui- 
lar;.-J  (;,}■„!, ,11  F./itioH.  Kdiied  liv  \.  (1  11  i,,\  1:ii,;ai;.  M.  |).,  I'rol'e.ssor 
ot  ()|„tetri,san.iCliniral  .Miduirerv!  Cornell  riii\erMt\  .Medi.  al  S,  hool. 
72  .  olored  plate>.  text  illiNirali.)ii>,  and  ,  (ipioiis  text,     'c  loth.  S5.00  net. 

Atlas   and   Epitome   of   Ophthalmoscopy   and    Oph- 
thalmoscopic   Diaglnosis. 

P.v  l>K.  ().  Hwi:,  of  /lirnh.  /■/,.,,,  ///,■  Th,,.!  R, ::,.:/  ,n,J  I-nlay,:i 
(,r, ,„.,'!  I:J,t,on.  r;dited  Kv  ().  I'..  lu  S,  Mut  IM  1 /,  M.  I ).,  Pr„feC>or 
ot  OphthalinoKw,  leri'ei.on  Medi,  al  (olle-e,  Philadelphia.  With  152 
<olore<l  li^iires  and  .S.'  pa-e^  of  texi.      Clotii.  5,^00  net. 

Atlas  and  Epitome  of  Bacteriology. 

In.  Iiidin,-a    lextPook   of  .spe,  lal    lia.  lenoloui.     Dia-nosis.      Pv  Pkof 
l»i<.  k_.   P.  Pi  hmann  and  1  )i<.   R.  (  >.  Nm  \mnx.  of  Wui/lHiri;.     /-row  Ihr 
S  .:'ii:i  R,r,<,-J{!,y.„.vi  i:jitiou.     I.ditedl.\  (;inK<;i   H.  W't'wiK.  M    D 
A>.istant  Profew)r  of  Pathol, ,-v  and  l!a,teriolo,,'v,      ash  Medual  (olle^'e! 
I  hhauo.       la,)    \oliinies    with    over   (100    ,  olored    lithoL'rai.hi,     lij^iires,' 
iMinert)us   text  illii^traiions.  and   500   pages  ol"   text. 

ADDITIONAL  VOLUMES   IN   PREPARATION. 

17 


NOTHNAGELS   ENCYCLOPEDIA 


■''if 


OF 

PRACTICAL   MEDICINE 

Edited  by  ALFRED   STENGEL.  M.  D. 

Professor  .  I  l  lin;.  .1:  Mcli.^ins  in  :hi-  Tniv  tT-i:v  .  '    I  Vi:i:s\  Kama  .   Visjunj 
rhysLiian  lu  the  I'ennsylvania  Hospital 

11    !■<  uiii\Lrs.illv  .ickiiuwlitl-Lil   thai  tlu-  ( iirni.iii-.   It. id  tin    uurKl    in   Intc-rn.il 
.\K(li(  in.'  ;  an. I  .  .t  .;11  tlK-  ('.1.1111,111  wi.rlo  im  tlii^  suIml-.  1.  Niithiia,i;frs  ■■  i;ii,\- 

cl..inili,i  ol  >ii..  i.il  ratlic>l..,;\  aii.l  'lln  rapt  uti.  s  "  i-,  ...nmUcl  '■>  si  lit.lar^  In 
liL-  uitlioul  (|iu-^ti..n  tlu-  best  Syitem  of  Medicine  in  existence.  So  nicts^ary 
is  this  book  in  tlu-  -imh'  ui  Int.  rnal  M.  iluiiu-  that  it  .  ..m,  ^  larL:i  ly  to  this  oonntry 
in  tlie  original  ( 'lurni.in.  In  \i.\\  ..l  ihr^t  lad--.  Mi-^--r-.  W  li  S.uimK  ix  \  ('..in- 
pany  have  arran,u;i--(l  ^^ith  thi-  piiLli^hi  1-.  t. .  i-r-ii.  at  oiicl  an  authorized  edition 
ol'  thi--  iirtal  <.-m'><'li>iii- ha   .  .t   iiRih.ni.'   in   llii-hsh 

I'..r  the  pn-i  lit  a  --ft  of  smm  ti-ii  or  tv.xKi.-  \.)hinK-^,  n.|irisLntin.i,'  thr  111.  st 
practical  part  of  this  enrvrlop.dia.  and  selerted  with  especial  thoufrht  of  the  needs 
of  the  practical  physician,  will  be  published  Tin-  volumes  \vill  contain  the  rt-al 
(..s-.-nif  ..f  lh>-  .-ntir.-  ni.rk,  and  the  pnr.'ha--.  r  nil!  then  fore  obtain  at  less  than 
halt  the  .list  the  cream  of  the  ori.uinal.  I. .iter  the  special  and  more  st'-'ctly 
scientific  volumes  will    be   oflered    from  time  to  time. 

Tile  ^^..rk  will  In-  tiMiisl.iiri!  ]■:  ni.  11  p.  .sscssin.;- tlmr.  .n-h  kn.  .u  Inl-e  ot  b.ih 
laiLili-h  and  (..  rmaii.  .ind  each  volume  will  be  edited  by  a  prominent  specialist 
on  the  subject  to  which  it  is  de\-..ted  It  will  tliu-  b.  br.ai-ht  thoronijhK  np  t.. 
date,  and  the  American  edition  will  b.  more  tli.iii  .1  men-  traii-.l,iti.  m  ..!  thr  (',,i- 
man  ;  tor.  in  .addition  t..  the  mail,  r  c.  .m.iiiual  in  the  .  .ri,i;in.il.  it  will  r,-pn-s,-nt  the 
very  latest  views  of  the  leading  American  specialists  in  the  \,uious  departnu  iiN 
of  Internal  Medicine.  The  whole  System  will  be  under  the  edit.iri.il  snper- 
\isi.  m  of  Dr.  Alfred  Stengel,  who  will  select  the  subiects  for  the  Am.rican  etlition, 
and  will  choose  the  editors  of  the  ililTerent  volumes. 

rnlik.'  111.1^1  encyci'ipi-dias.  ili.-  public, ition  of  this  wurK  will  not  be  extended 
over  a  number  of  years,  but  fm-  or  -i\  \.i|nme'-  \\ill  be  i-sued  diirinu  tin  coniin<; 
\<ar.  ,ind  till-  rem  iindi-r  ot  tlu-  srri.s  ,u  tin  sain-  r,ite.  Moreo\.r,  each  volume 
will  111-  re\i-.id  t..  the  il,it.-  ,if  its  publicitfon  b\  the  Anuri(-,in  eilitor  This  will 
obviate  the  objection  that  h.is  li,  r.-t.  .1.  .ri-  1  \istf.l  to  syst.  iiis  publisheil  in  a  number 
of  volumes,  since  the  siibsirib.-r  will  ro.ive  the  compli  I>  tl  w-vk  while  the  earlier 
volumes  ar.'  still  fr<  sh. 

The  iisu,il  niilh...!  ol  publishers,  when  issniiv.:  .1  w .  irk  ot  this  kind,  ha--  been 
In  ciiinpel  |>h\sici,iii-,  td  t,ike  the  ontir.'  .S\st.ni,  This  se.iiis  i..  us  in  ni.iin  cases 
to  In  un.li-.irable.  Tli.  refore.  in  pur.  h.isiiiL;  this  eiicyi-h  .ped.i.i.  plixsiciaus  \v  ill  In- 
:^i\en  ill.-  .i|iportnnit\  of  --nbscribin'.:  lur  lln'  eiitir.'  Sy-tiin  at  oni' time  ;  but  .iii\- 
sinjjle  v..luiiie  .ir  ,iny  nunib.  r  nl  \..liinus  max  be  obtained  by  th.'-i  w  lio  d.i  not 
desire  111.'  I  .iinpl.  tr-  si  rie--  This  l.iiirr  nuthoil.  while  not  so  pr  litable  to  tlu  ]iuli- 
lisher,  offers  to  the  purchaser  many  advantages  win.  h  will  be  .i;  ■  ciated  b\  those 
who  tl.i  11.4  c,ir.-  t.i  subscribr  fur  ih.    ■  iitin-   work  .it   .  hu-  lini.'. 

This  .Anirri.  .Ill  ..lili.iii  .  .i  N.iihi;r_iT~  bn.  \ .  1.  ipi  .lia  will,  without  i|Utstion. 
foi  in  the  greatest  System  oi  Medicine  ever  produced,  ami  tli.  publi-hers  i.  ei  con- 
tidiut  th  ii    it   ■Alii   111.  et   \\\'\\  l;.  n.ril   la\i.r   in  l!:-    ri-.li.al   profession. 


NOTHNAGEL^S  ENCYCLOPEDIA 

VOLUMES  JUST  ISSUED  AND  IN  PRESS 

VOLUME  I  VOLUME  VTI 


Editor,  William  Osier,  M.  D..  F.R.C.P. 

Pfijeiwr  i>/  Mcii.i-i'  inM'"!'  //.'/><"■•• 

t'ni'  >  rsity 

CONTENTS 


Typhoid  Fever.     1^   I'^"    <- k-o.masn 
c.i  l,t.-ii>~ic.     Typhus  re ■.'( 


.[  lA-u-ic.     Typhus  Fever.     l''y  '"-^     "■ 


Hati'iMime  ■■' 


Editor,  John  H.  Musser,  M.  D. 

,  r/ew  .'/  Oini^al  M.autK.  .  I  'ii:tr.ity  ,/ 

CONTENTS 

Diseases  of  the  Bronchi.  I'..  "^  , '•  ^'^  J'  '  ' ' 
M  \NN.  .1  1.,  ii.-;c.  Diseases  of  the  Pleura. 
l.v  PK.  R"-i  Ni  A'  ii,>'l  l;<;rlin.  Pneumonia. 
\i^    I'K.    1'.   Av  I  V:l  '  HI,  uf    Ma-' Iti'in i;. 


VOLUME  II 

Editor.  Sir  J.  W.  Moore.  B.  A.,  M.D., 

F.  R.  C.  P.  L.  of  Dublin 

/■r.y.J.-."- .!/"  /•'••»'-"■''  "/  -W.'/"""-.  '^■'V"'  ^••■•<f 
c/  Suti.-Ci.-n!  .•■;  IreUit.i 

CONTENTS 

Erysipelas  and  Erysipeloid.    I'.v  1  'R-  H  I;  v 

H^ri/  ui  lUiiu'am.    Cholera  Asiatica  and 

Cholera  Nostras.    '■>  "J^^";  '^'". 
MiiMiK   "I    Uii'in-LMi.    Whooomg  Cough 

and  Hay  Fever.     ''X  "^  ''./'"  ^'ir, 
.., ..-.en    Varicella.    IM'^.  In  n"NJ','^ 
,iNMN   of    rubint;.-!!.    Variola    including 
Vaccination.    lyl'K.U   Mm.knusn.'T 
l;a~le. 
Haiid'ome  ..uav.i  volume  .if  ..%<.t  700  i-ag". 
/!<!.■  /.j-'i.-.l' 


VOLUME  VIII 
Editor.  Charles  G.  Stockton,  M.  D. 


r-,.,,,T      /.lA'./.. 


liu; 


CONTENTS 


Diseasesof  the  Stomach.    I'.v  !"<■  1     l-^'^''"' 


VOLUME  IX 
Editor,  Frederick  A.  Packard,  M.  D. 

CONTENTS 
Diseases  of  the  Liver,    l^y  1 'u-.  1 1. ',"  .N' k, 
.iin!  1..  ll....n->i  VMK,  oi   Kul. 


VOLUME  m 
Editor,  William  P.  Northrup,  M.D. 


/v,/.-, 


CONTENTS 


M,a,les.  r.v  1)k.  Til.  v..s  JCruKSMN,  .ii 
lu!:^,.,:.  Scarlet  Fever.  1'-  -l';-  --» 
.uith.T.     Rotheln.    l-.v  llH. -uiie  nuilu.r. 


VOLUME  VI 
Editor,  Alfred  Stengel,  M.D. 

.'',■'11  n'riiKht 

CONTENTS 

Anemia.  I'V  T'R-  ^  ''■"'^' '  "•  *"'  r'^nUfort- 
'^ "uT-Main,  .na  Lk,  A.  La/aki>.m  I  li.r- 
lotttnburg.  Chlorosis,  '''y.!'^,  "^  ^'.'^ 
N..ciK')i.'N,  nf  Kinnklo,t-<Mi  in. -Mam  Dis- 
eases of  the  Spleen  and  Hemorrhagic 
Diathesis,    r.vl-..  M.  1.,miv,.-i    |.-n,n. 


VOLUME   X 
Editor,  Reginald  H.  Fitz,  A.M.,  M.  D. 

J/,^s,-y  /v../;jj,.r  ,//■•;.■  7-V,.  ■.r,i«.rW,u:/,.- 
,  /■  /'lyiic,  }ljr-.'ird  Ca.vfnily 

CONTENTS 

Diseases  of  the  Pancreas,     l'^^'  I^k.  I    >  ''-fR. 
,l   Vi^nii.i.     Diseases  of  the  Suprarenals. 

r.v  1>K.  K.  Nki  -sr.K,  ul   \  iciin.a. 


VOLUMES  rV,  V,  and  XI 
Editors  announced  later 

V.,1.  IV. -Influenza  and  Dengue,  ''y  ,"'~- ^■ 
1  I  K  nil  N^TtuN, I'll  "li'UiH  MalanalUu- 
eases.    I'V  I'^.J-  M  vnn  m.i  R'- '  '   Vicm.,. 

v.  ',  \  -  Tuberculosis  and  Acute  General 
MiUary  Tuberculosis,    l--  1 'k.  i..  <    .km  i, 

\' .1  \1  Diseases  of  the  Intestines  and 
Peritoneum.  l''y  !"<•  "■  -N'-""^agh„ 
pf  \  icniia. 


19 


-:  rr..t.t-^J 


'IS    .11' 


CLASSIFIED  LIST 

OF  THE 

MEDICAL    PUBLICATIONS 


or 


W.  B.  SAUNDERS  O  COMPANY 


^. 


i'i 


m\ 


ANATOMY.  EMBRYOLOGY, 
HL^^TOLOGY. 
Bohm,    Davldoff,    and   Huber    A  Um- 

book  of  Hl>t  'h  i;v 4 

ClarkBOP— A  Tixt  lio  >knf  Iliiiology.  .    .     5 
HayDes — A  Manual  of  Ai.;iloinv 7 

HeUler^ATcxt-r.oi.k  c.f  Kinbrv'ul'-iK'y.  ■    •  7 

Leroy -Ks,emial>  of  lli~t..lui:y'         '.  i; 

Nancrede  -  l^ssontialsul  Aiiatumv 15 

Nancrede— 1;->' niials    ol    Anat.iinv    ^md 

Manual  of  l*rac:ic.il   I  Ji>M-til>iii,  10 

BACTERIOLOGY. 

Ball — 1  ss.nlialbOf  li  it'trioloj;)- 15 

Frothlnghara  — I.alior.iiory(iuicle 6 

Oorham     1.  iM'Mt.ay  ''"urs.'  in    Bacieri- 


Lebmann  and  Neumann— Ail  is  cf  Rictc- 

fiol.'ijy 

Levy  and  Klemperer  s  flinica!   V,j  i  r  - 

..1   ;;v 

Mallory  and  Wright- I' [tl,uluL;Kal  !<■  :, 

nique 

McFarland— I'aiho^-fiiic  Iia  '■  r.a 

CHARTS,  DIET-LISTS.  ETC. 

GrlfBth— liifmi  bW,  -:.t  C!,  it,  . 
Hart— Iiui  in  Mcknc,  ami  in  litiUii. 

Keen  -I  >peratiMn  H  ank 

Lalne — IcnifieraTurr  i  iia:I 

Meigs — iVedini;  in  Early  Infancy 

Starr  -1)  iis  f..r  Infants  and  Children.  .    . 
Thomas  — liKi  Li- ts 

CHEMISTRY  AND  PHYSICS. 

Brockway- K5-i-nti  ilsnf  Medical  I'hvsics, 
Wolff— l■;^senti  lis  of  Medical  Chcmistrv,  . 

CHILDREN. 

An  American  Text-Book  <!   Id^im^is  of 

nnl'lrm 

Griffith -I '.ire  if  tlie  li.iljv 

Griffith  -Infints  Weitjht'ciMrt,  .   .    . 
Meigs   -li-cdini;  m  I'.arlv  Infancv.  .    , 
Powell— Kssentials  of  Diseasi";  of  Children. 
Starr -Diets  lor  Inlanis  and  Children. 

DIAGNOSIS. 
Cohen  and  Eshner-1.  -cntn.^  of  Diag- 


EYE,  EAR.  NOSE.  AND  THROAT. 
An  American  Text-Book  of  Disease    oi 

the  l-.u;,  I-;, I,  N.ise,  ,ind    Ihr.i.lt I 

De  Schwelnltl  — Di-eases  of  the  Kve,  .  .  0 
Frledrlch  and  Curtis— khinoiugv,  Lirvn- 

l:.':o^'v  and  OtoloL;> 6 

Oleason  — l'..~eliti.ils  of  Diseasesolthe  F.a; .  15 

Oleason  -I-ss.  of  Dis.  of  No>e  and  Throai  15 

Gradle  -I'.ai    No  ■•.  and  Tin. ..it 22 

Grilnwald   and    Grayson- .\tl  is  of  Di^ 

e.is '5  "t   t:.-'   I.  ir\  n\ 16 

Haab  and  De  Schwelnltz  -.Atla-^  of  I'xter- 

n  '1  Di-e.i-e-  .   1    tie     l.\e if, 

Haab  and  De  Schwelnltz     At  a=  of  1  'ph 

t  .  ilmos^ ,  ,:.\-, 17 

Jackson  — \I.inu.il  o'    D  s.  a^i  s  of  tin-  l-.v  ■,  s 

Jackson— li,^entl.lI.S    of     Diseases   of     lye,  it; 

Kyle —Diseases  of  the  Nos,-  .-md  'Ihroat,  .  9 


GENITOURINARY. 

An  American  Text-Book  of  Genito-fri- 

n.iry  and  Skii.  Di>  a^e^ 

Hyde  and  Montgomery  -Syphilis  and  the 

\'enereal   I)iseases 

Martin — !>sentiil.i     of    Mm.-r     Surgery, 

li.iiulai.' 111;  ind  Venereil  Diseases.  .  ,  . 
Mracek  and  Bangs— .\tlas  of  Syphilis  .md 

tiie  \'enere,il    Dlse.ises 

Saundby — Renal  and  Crmarv  D  seases.  .  . 
Senn  ilenito-Crinarv  Tuberculo-is,  .  .  . 
VecU — Se.\iial    Imp  itence 


GYNECOLOGY. 

American  Text-Book  nf  Gynecolog)-,   .   .  3 

CrajCln- l^baelltl.rLiof  i;vneCiilof;v 15 

OarrlgUeS— l.)|sea-e,  oj   \\'..men 6 

Long — >yliabus  of  GynecoloLiv 9 

Penrose — Diseasi  s  of  Women    .    .....  10 

Pryor— I'eb- c  Ir.tlunm  ili.-ins        11 

Schaeffer  &  Norrls -.Vtl.i-  o!  Gynecology,  17 


HYGIENE. 

Abbott — Hx'giene  o!  ri,,nsnii~ 
Bergey— Principles  of  llvpiei 
Pyle-lVr~ mil   ll\  .,'1.  nc  '  '    . 


■il'le  Di-enses    3 

e 22 

II 


Corwln  — I'hvsiial   Diaunobis 

Vlerordt— .\ie.li,al  Dri-nosis 

DICTIONARIES. 
The  American  Illustrated  .M.  las!  Du- 

tionnr\' 

The  American  Pocket  Medical  Di  ti  narv, 
Morten —Nurses'  Dictionar\- 


MATERIA  MEDICA.  PHARMACOL- 
OGY, AND  THERAPEUTICS. 

American  Text-Book  <ii  1  liei.ipeuties,  ,    .  , 
Butler— re\l-liook    of     M.iteii.i    Mcdica. 

Mier.ijieutics.  .md  I'iiarm.iec.logy.    ...  4 

Morris— Kss.  of  M.  M.  and    Thenipeutiis,  15 

Saunders'  I'oeket  Medical  I-orniular\,      ,  11 

Sayre- I'.-.entials  of  I'harn-ai  y.  ,    .   ',    .    .  15 

Sollmann— r.'xt-li  'ok  cf  Pharm.icologv.  .  22 

Stevens— M.inu.il  ol  ■rherapeuiKs,   .  '    .  i} 

Stoney  — Materia   Medic.i   f.r  Nurses.    ,  jj 

Thornton— Prescription-Writing 13 


20 


MEDICAL  PUBLICATIONS  OF  W.  B.  SAUNDERS  .-  CO. 


MEDICAL  JURLSPRUDENCE  AND  SKIN  AND  VENEREAL 

TOXICOLOGY  An    American     Text-Book     ui     l-n. 

Chapman— Ml- die.  1   |mis|.Mid.n>  c  nnd  Hyde  and  Montgomery— ^>l>l'.l:.  a"  J  il"-' 

roxi..il'»;v,  .,  ■/,,  ^        \,'v'.n\   111M.1-.S ,'    "    ' 

Ooleblewskl  and  Bailey -Atli-  of   Pi,-  igartln- I>sentiaU    of     Minor    Surgity 

ra^^rs  (  ausi  cll.v  A.    iilinl^.                t         i  '^         Hand  is^iiii;,  '  nl  V.-n.-rrrill  H-.n  >■>,     .        15 

Hoftnann  and  Peterson    Atl.is  ■  f  !.•  uril  jjraceltand  jtelwagon— Vthi^ot  Ui»ea  e:, 


Mc.ll.in. ■    ■    ■ 

NERVOUS  AND  MENTAL 
DISEASES,  ETC. 

Brower— Minunl  of  Insnnit  ■ 2  = 

Chapln-i-'-'inpfti'l'"'"  of  '■    '""^•,   ■         ? 
Church  and  Peterson     Nervuu^  a  .1  M^  n-     _ 

Jakoh&Visher   - Ath.ofNi  m- >^-'  'em,   17 
Bliaw—l;sseniial5  of  Nervous  Ui-ea-t    ir 
lllbarnly.  ■ 

NURSING. 

DavlB-nhsttlrican'Hivnrcui.igicNur-in 
Orlfflth-TlK' Can  of  ihi-  li  ibv    .    .    . 
Hart— Uit-l  in  ^itkncss  and  111  Healih, 
Melgs-KiTdiiig  in  l.irly  Infancy.  .    .    . 
Morten  -  Nurses'  l)xliunaiy, 

Btoney  — Mitcria  Miilica  for  Nir  -c,. 

Btoney     I'mctica;  I'oinii  in  Nursinc;,  ■    • 

Stoney- Surgical  'Ii-ilinic  fcjr  Nurses, 

Watson— Handbook  foi  Nurses, 

OBSTETRICS, 
An  American  Text-Book  of  ( n.sietr  cs, 
Ashton-1'.ssem..ils  t)l  t-ibsieirus,    .    .    . 
BolsUnlAre— Libsieinc  Aceiii-nis,   .    .    . 

Borland  -Mo.ieni  Ob:tptric5 

Hirst  ~le\t-Uook  of  Obsietrus,     .    . 
Norrls  -Svllal.us  of  t^bsletrics 


Stelwagon- 


-1;,,    Mil    1,   of  lJi  =  eaes  of  tlie 


16 


SURGERY, 


ami 


Schaeffer  and  Edgar-Atlas  of  Obstetn- 

cal  Ui.ignus.s  anil  Ire. itment i/ 


An  American  Text-Book  'f  Siireerv. 
An  American  Year-Bookoi  M.  .i,vi.uai,(l 

>-iiii;'rv, 

Beck— l-iic  Hires 

15     Beck-M.uiua;  .it  Surgieai  Asepsis      .    . 
DaCosta— Manual  of  Surgery,  . 
International  Text-Book  ol  Surgm 

6  Keen  -  <  ip'rauou  141, uik 

7  Keen— lie    Surgical    Compl.cat.un 
7         ^L.,|uel- o'  Tvphoii!  Fev.r.    .    .      _    ■ 

10     Macdonald— Surgical  Ui  .gnosi-an.lTrc.t- 

10         nient ■ 

I',     Martin  -  Hsstnii  lis    o:     Mm^  r    Mirg.ry. 
13         Hand.ging,  aiuiVcTu  re.il  DiseaMs,      .    . 

13  Martin-  Ess,nti.ds  of  Surgery 

14  Moore  — <  ii'bopedie  Surgery 

Nancrede-rriu.iples  of  suigerv.  .    . 
pye— li.indaging  and  Surgical  Dn-s-in^. 

2     Scudder      1  le.itni. m  of  Irauuies.     .    . 
I-,     senn-  leniu.-Uru.iry  Tub-rculosis,  .    . 

4     Senn-  rractical  Surgery 

t,     Senn-Svllabiis.4  >urgery.        _ 

7     Senn— I'athology  and  Suig.c  d  Treatn,.  nt 

(,1    lumors, , 

Warren— Surgical  Tathologv  and   Ih.ra- 


5 

3 

■) 

15 
>S 
10 
10 
II 

13 
12 
13 


tl'.n, 

I J    Wolff— Essentials 
12         L'line 


Zuckerkandl   and   Da   Costa-Adas    ol 

PATHOLOGY.  eiper.nive  Mirgerv.  .    .  ■    ■  " 

SSi^S'SeJ^^A^.lsdf'l'dl^^og.c    ;    URINE  AND  URINARY  DISEASES. 

Hi-tology.      ■■,■■•;; !J     oeden-'bnic.alExan.mau.mof  the  Urine.    10 

Kalteyer-F.-senlalsof  P.uliol-c'x    _   .        I:,     °83by-Renal  and  Urm.iry  U.eases.        11 
MalloryandWnght-KdhcogicUTec.       ^     ^^'^^^Handbook     of      Urine-Ex.nmina-    ^^ 

Benn—i'atholosy  and  Surgical  ■Ireaiui.nt  „'J;;^''     V...,'nf',nl=  '  nf  '    Exaniiuiti'm     of 

of  Tumors •    ■    ■    • 

Btengel-Text-Book  of  I-athoIogy._    .    ■    i^ 
Warren- Surgical  I'athology  and  Th-T..-    ^ 

peuli'S 

'PHYSIOLOGY,  Bastln- I.aborai..M  l-.xercs.s  in  Botanv.  .      4 

.nAmerlca^^f^-ology,     3    0<.eh.ws.  -  BaU,.  .Vtias  of  O.s- 

Budgett -Essentials  of    P'-V'o'.oS).    ■    ■    -^ 
F.aymond-rext.l!o..k  of  I'liyMologv.  .    . 

Stewart- Minual  of  rhvsuilnL-v.        ■    ■ 

PRACTICE  OF  MEDICINE. 

An  American  Year-Book  m  Me.bcne  and     ^  ^  g^;^ie„.-Mr,lical  Hand-Atla-e~       .    .  16,17 

II 

I.t.ls 


f      Exainin  iti'in 

MISCELLANEOUS. 


'3 


17 

Oould  and  Pyle— .\nonialies  and  Curiosi- 
ties of  Medicine ^ 

Orafstrom— Massage,    ...   •••■•■     ^ 
Keating— How  >o  Examine  for  Life  Insur- 
ance, 


■J  1  Saunders'  Medical  HandAlla-e- 

1  I  Saunders'  Pocket  Medical  Koimuiary. 


Anders-Practice  of   ^'i'',i«;_'nf_;^_   •    ■    "    ;     ^  |  gaunderb'  Quest.nn-rompends 


Elchhorst-Practice  of  Medicine,  .    ■    ■ 
Lockwood  -Manual    of    tl.e    Practice    of 


!  Stewart    and   Lawrence— Esentials 


of 


,,  ,       Medical   I-.lectri  itv,     . 

Medicine •  ■    ■    ■    ■        ,- I  Thornton-    Dosc-Hook    and    M.inual    ct 

Morris-Ess,  of  I'laciice  of  Med.c.ne,       ,_,,  Thornton  ^      ^^. ^^ 

Salinger  and  Kalteyer-Modem   Medi-  ^  j  .yj;^^'.^;jlaii  and  Kisbet-Diseases  of  the   ^ 

8t^'y'ens-M-.nualofI'racticc  of  Medicine,    .3'      S-omadi '3 


.'    .        J       'J  < 


THE  LATEST  BOOKS. 


Bergey's  Principles  of   Hygiene. 

Ihc  I'unciplc-i  of  lIy:,rK.nc:  .\  Practical  M.uui.il  U,r  Students. 
I'liyMciiii,.,in.l  M.altli  ortlccrs.  \W  D.  |i  lli-ki.ia  ,  A.  M,  .M  1 )., 
Fir-t  AsM.tant,  Laboratory  ..f  I  ly.^icnr.  L-nivcrsity  of  IVnnsyl- 
vania.      Haiulsomc  octavo  vohuii  •  of  al.out  500  pa^es  illustrated. 

Brewer's  Manual  of  Insanity. 

A  Practical  .Manual  of  Insanity.  By  Daniki.  R.  Hk,,\vi;k,  .M.  1).. 
Professor  of  Xervous  an^l  Mental  Disease^,  Rush  Medical  (;olle<,'e. 
Chicago.       i:;nio  volume  of  425  jiages,  illu.strated. 

Gorham's  Bacteriology. 

A  Laboratory  C.urse  in  Hacteriojo-y.  hy  p.  p.  Gokii.\.m,  .M.  .\., 
Assistant  Professor  in  Hiolo-y,  Hro..vn  University.  12,1,0  volume 
of  about  160  pa-es,  handsomely  illustrated. 

Gradle  on  the  Nose.  Throat,  and  Ear. 

Diseases  of  the  Xose,  Throat,  and  liar.  Ry  Hexrv  Gk.ai.i.e. 
^^.n,,  Profess,,r  of  Uphthalmol.;,-y  and  (nolo:^^y.  Northwestern 
University  Medical  .School,  Chicago.  ILand.some  octavo  volume 
of  Soo  pages,  profuselv  illustrated. 


SoUmann's  Pharmacology. 

A  Te.vct-Hook  n\  Pharmacology.  Ry  Tok.\,.„  Soll.m.xnn,  .\L  D.. 
Lecturer  on  Pharmacologv.  Western  Reserve  University,  Cleve- 
land, Ohio.      Ro>Td  octavo  \-olume  .,f  about  700  pages. 

Wolfs  Examination  of  Urine. 

A  Handbook  of  i'hysioh.gic  Chemi.stry  and  Urine  Examination. 
Hy  CiiAs.  (-,.  L.WorF.  M.I).,  Instructor  m  Physiologic  Chemistry, 
Cornell  University  Medical  College.  i3mo  volume  of  about  160 
pages. 


f 

r 

r 


'■\: 


